Provider Demographics
NPI:1073552683
Name:MOSES, TINA PERRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:PERRY
Last Name:MOSES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 WINDMILL PKWY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6664
Mailing Address - Country:US
Mailing Address - Phone:706-863-4524
Mailing Address - Fax:706-863-4524
Practice Address - Street 1:1240 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1854
Practice Address - Country:US
Practice Address - Phone:706-863-6262
Practice Address - Fax:706-863-6465
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG2036Medicaid