Provider Demographics
NPI:1467501197
Name:MOSS, SAMUEL R, (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R,
Last Name:MOSS
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 1:217 E KALISTE SALOOM RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8513
Mailing Address - Country:US
Mailing Address - Phone:337-232-9937
Mailing Address - Fax:337-232-1172
Practice Address - Street 1:217 E KALISTE SALOOM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8513
Practice Address - Country:US
Practice Address - Phone:337-232-9937
Practice Address - Fax:337-232-1172
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist