Provider Demographics
NPI:1457499972
Name:MOELLER, JAMES CARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CARL
Last Name:MOELLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 SOUTHWYCK BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1534
Mailing Address - Country:US
Mailing Address - Phone:419-865-1201
Mailing Address - Fax:419-865-1061
Practice Address - Street 1:5445 SOUTHWYCK BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1534
Practice Address - Country:US
Practice Address - Phone:419-865-1201
Practice Address - Fax:419-865-1061
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0201052Medicaid