Provider Demographics
NPI:1598095523
Name:LITTLE GRINS
Entity Type:Organization
Organization Name:LITTLE GRINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOSELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS , MSD
Authorized Official - Phone:928-317-9494
Mailing Address - Street 1:2179 W 24TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6163
Mailing Address - Country:US
Mailing Address - Phone:928-317-9494
Mailing Address - Fax:928-782-2212
Practice Address - Street 1:2179 W 24TH ST STE B
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6163
Practice Address - Country:US
Practice Address - Phone:928-317-9494
Practice Address - Fax:928-782-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty