Provider Demographics
NPI:1518228485
Name:MIDWEST DENTAL JEFF MOOS DDS PC
Entity Type:Organization
Organization Name:MIDWEST DENTAL JEFF MOOS DDS PC
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:680 HEHLI WAY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1639
Mailing Address - Country:US
Mailing Address - Phone:715-926-5050
Mailing Address - Fax:715-926-4269
Practice Address - Street 1:300 WALMART DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-3333
Practice Address - Country:US
Practice Address - Phone:573-860-2552
Practice Address - Fax:573-860-2553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty