Provider Demographics
NPI:1306398300
Name:RUSSELL MOSHER, DDS, PC
Entity Type:Organization
Organization Name:RUSSELL MOSHER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-379-6971
Mailing Address - Street 1:1320 ALVERSER PLZ
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2604
Mailing Address - Country:US
Mailing Address - Phone:804-379-6971
Mailing Address - Fax:807-379-2796
Practice Address - Street 1:1320 ALVERSER PLZ
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2604
Practice Address - Country:US
Practice Address - Phone:804-379-6971
Practice Address - Fax:807-379-2796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-26
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010071131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty