Provider Demographics
NPI:1629176714
Name:MOEN, RICHARD HUGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HUGH
Last Name:MOEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-0566
Mailing Address - Country:US
Mailing Address - Phone:320-589-2161
Mailing Address - Fax:320-589-3149
Practice Address - Street 1:201 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1212
Practice Address - Country:US
Practice Address - Phone:320-589-2161
Practice Address - Fax:320-589-3149
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN02297097Medicaid