Provider Demographics
NPI:1215574017
Name:MOUA DENTAL PC
Entity Type:Organization
Organization Name:MOUA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-810-0978
Mailing Address - Street 1:1770 BLUEWATER LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1770 BLUEWATER LN
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-6236
Practice Address - Country:US
Practice Address - Phone:612-810-0978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental