Provider Demographics
NPI:1629736467
Name:MOSSMAN DENTAL PLLC
Entity Type:Organization
Organization Name:MOSSMAN DENTAL PLLC
Other - Org Name:THE DENTAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-838-3772
Mailing Address - Street 1:PO BOX 195487
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:634 SUNLAND PARK DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5138
Practice Address - Country:US
Practice Address - Phone:972-838-3772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty