Provider Demographics
NPI:1659433738
Name:DRS MOORHEAD& ROSS DDS
Entity Type:Organization
Organization Name:DRS MOORHEAD& ROSS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-874-3731
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929
Mailing Address - Country:US
Mailing Address - Phone:907-874-3731
Mailing Address - Fax:907-874-3531
Practice Address - Street 1:215 FRONT ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-874-3731
Practice Address - Fax:907-874-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5501223G0001X
AK5701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDD0550 DD0570Medicaid
AL=========OtherBLUE CROSS
WA=========OtherBLUE CROSS
=========OtherAETNA & MISC.