Provider Demographics
NPI:1750406674
Name:MOSS, MICHAEL ARNOLD (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ARNOLD
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17295 HIWAY 101 N
Mailing Address - Street 2:
Mailing Address - City:SMITH RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95567-9406
Mailing Address - Country:US
Mailing Address - Phone:707-487-8700
Mailing Address - Fax:707-487-3700
Practice Address - Street 1:17295 HIWAY 101 N
Practice Address - Street 2:
Practice Address - City:SMITH RIVER
Practice Address - State:CA
Practice Address - Zip Code:95567-9406
Practice Address - Country:US
Practice Address - Phone:707-487-8700
Practice Address - Fax:707-487-3700
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice