Provider Demographics
NPI:1346264181
Name:MOSS, ROBERT BURGESS JR (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BURGESS
Last Name:MOSS
Suffix:JR
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 1:1600 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3461
Mailing Address - Country:US
Mailing Address - Phone:229-432-2103
Mailing Address - Fax:229-432-2114
Practice Address - Street 1:1600 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3461
Practice Address - Country:US
Practice Address - Phone:229-432-2103
Practice Address - Fax:229-432-2114
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics