Provider Demographics
NPI:1073594891
Name:MOORSE DENTAL PSC
Entity Type:Organization
Organization Name:MOORSE DENTAL PSC
Other - Org Name:OLIVIA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MOORSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-523-1441
Mailing Address - Street 1:907 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVIA
Mailing Address - State:MN
Mailing Address - Zip Code:56277-4215
Mailing Address - Country:US
Mailing Address - Phone:320-523-1441
Mailing Address - Fax:320-523-1441
Practice Address - Street 1:907 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OLIVIA
Practice Address - State:MN
Practice Address - Zip Code:56277-4215
Practice Address - Country:US
Practice Address - Phone:320-523-1441
Practice Address - Fax:320-523-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120523400Medicaid