Provider Demographics
NPI:1154314664
Name:MOSLEY, RONALD O (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:O
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8909
Mailing Address - Country:US
Mailing Address - Phone:912-537-4119
Mailing Address - Fax:912-537-9117
Practice Address - Street 1:310 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8909
Practice Address - Country:US
Practice Address - Phone:912-537-4119
Practice Address - Fax:912-537-9117
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0104151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA19NCBDQMedicare ID - Type Unspecified
GAU22619Medicare UPIN