Provider Demographics
NPI:1538301411
Name:MOS CORPORATION
Entity Type:Organization
Organization Name:MOS CORPORATION
Other - Org Name:UNION AVE DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ONEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-276-7314
Mailing Address - Street 1:1331 UNION AVE
Mailing Address - Street 2:STE 1225
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3513
Mailing Address - Country:US
Mailing Address - Phone:901-276-7314
Mailing Address - Fax:
Practice Address - Street 1:1331 UNION AVE
Practice Address - Street 2:STE 1225
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3513
Practice Address - Country:US
Practice Address - Phone:901-276-7314
Practice Address - Fax:901-276-6028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531369Medicaid