Provider Demographics
NPI:1518986314
Name:MOSS, MATHEW A (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:A
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4701
Mailing Address - Country:US
Mailing Address - Phone:307-587-9009
Mailing Address - Fax:307-587-9444
Practice Address - Street 1:1817 17TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4701
Practice Address - Country:US
Practice Address - Phone:307-587-9009
Practice Address - Fax:307-587-9444
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics