Provider Demographics
NPI:1235522491
Name:MOULDS FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:MOULDS FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MOULDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-894-3490
Mailing Address - Street 1:4620 HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-3000
Mailing Address - Country:US
Mailing Address - Phone:423-894-3490
Mailing Address - Fax:
Practice Address - Street 1:4620 HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-3000
Practice Address - Country:US
Practice Address - Phone:423-894-3490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty