Provider Demographics
NPI:1598053712
Name:BRET E. MOOSO D.D.S.,M.S.
Entity Type:Organization
Organization Name:BRET E. MOOSO D.D.S.,M.S.
Other - Org Name:MOOSO ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOOSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-522-4552
Mailing Address - Street 1:1580 ELK CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6269
Mailing Address - Country:US
Mailing Address - Phone:208-522-4552
Mailing Address - Fax:
Practice Address - Street 1:1580 ELK CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6269
Practice Address - Country:US
Practice Address - Phone:208-522-4552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty