Provider Demographics
NPI:1265681365
Name:MOSS, GARY WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WALLACE
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1680 WESTWOOD DR STE D
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5105
Mailing Address - Country:US
Mailing Address - Phone:408-266-4444
Mailing Address - Fax:408-266-4457
Practice Address - Street 1:1680 WESTWOOD DR STE D
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5105
Practice Address - Country:US
Practice Address - Phone:408-266-4444
Practice Address - Fax:408-266-4457
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA232191223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics