Provider Demographics
NPI:1609407907
Name:MOSES ORAL AND FACIAL SURGERY LLC
Entity Type:Organization
Organization Name:MOSES ORAL AND FACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-299-0270
Mailing Address - Street 1:202 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3009
Mailing Address - Country:US
Mailing Address - Phone:662-219-0044
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3009
Practice Address - Country:US
Practice Address - Phone:662-219-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07720764Medicaid