Provider Demographics
NPI:1184160566
Name:DARIN R. MOOSO
Entity type:Organization
Organization Name:DARIN R. MOOSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOOSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-455-0033
Mailing Address - Street 1:4105 CLOCK TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5006
Mailing Address - Country:US
Mailing Address - Phone:208-455-0033
Mailing Address - Fax:208-455-8535
Practice Address - Street 1:4105 CLOCK TOWER AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5006
Practice Address - Country:US
Practice Address - Phone:208-455-0033
Practice Address - Fax:208-455-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9202299Medicaid