Provider Demographics
NPI:1568978856
Name:GREGORY J MOOS DDS PC
Entity Type:Organization
Organization Name:GREGORY J MOOS DDS PC
Other - Org Name:FOUR CORNERS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-495-5131
Mailing Address - Street 1:380 ICE CENTER LN STE B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-5970
Mailing Address - Country:US
Mailing Address - Phone:406-586-9871
Mailing Address - Fax:406-522-0586
Practice Address - Street 1:380 ICE CENTER LN STE B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5970
Practice Address - Country:US
Practice Address - Phone:406-586-9871
Practice Address - Fax:406-522-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty