Provider Demographics
NPI:1538482377
Name:MOSS, LISA MAURIOCOURT (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MAURIOCOURT
Last Name:MOSS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24144 WESTMONT DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24144 WESTMONT DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-3660
Practice Address - Country:US
Practice Address - Phone:248-797-8632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178651223G0001X
GADN0108551223G0001X
SC30011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice