Provider Demographics
NPI:1477738961
Name:DR. DALE J MOSER OD
Entity Type:Organization
Organization Name:DR. DALE J MOSER OD
Other - Org Name:BEAVERTON FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:989-386-2020
Mailing Address - Street 1:1520 B N MCEWAN ST
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617
Mailing Address - Country:US
Mailing Address - Phone:989-386-2020
Mailing Address - Fax:989-386-7308
Practice Address - Street 1:334 N ROSS
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612
Practice Address - Country:US
Practice Address - Phone:989-435-2020
Practice Address - Fax:989-435-2554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. DALE J MOSER O.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003085152W00000X
MI003085332H00000X
MI004640332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A86500OtherBC/BS
MI1908862Medicaid
MI410008233OtherRAILROAD MEDICARE
MI410008233OtherRAILROAD MEDICARE
MI1908862Medicaid
MI2671940002Medicare NSC