Provider Demographics
NPI:1043332844
Name:MOSS, KEVIN CARROLL (DMD MS PLLC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CARROLL
Last Name:MOSS
Suffix:
Gender:M
Credentials:DMD MS PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 CORPORATE CENTER LOOP SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-491-7080
Mailing Address - Fax:360-491-7105
Practice Address - Street 1:5320 CORPORATE CENTER LOOP SE
Practice Address - Street 2:SUITE A
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:360-491-7080
Practice Address - Fax:360-491-7105
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0700009204122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics