Provider Demographics
NPI:1497105688
Name:MOSS, LISA DIANE (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:MOSS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5047 VIRGINIA AVE
Mailing Address - Street 2:BLDG 500
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9126
Mailing Address - Country:US
Mailing Address - Phone:573-596-0408
Mailing Address - Fax:573-596-0314
Practice Address - Street 1:5047 VIRGINIA AVE
Practice Address - Street 2:BLDG 500
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9126
Practice Address - Country:US
Practice Address - Phone:573-596-0408
Practice Address - Fax:573-596-0314
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015980124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist