Provider Demographics
NPI:1679534580
Name:DATSON, MOSES
Entity Type:Individual
Prefix:DR
First Name:MOSES
Middle Name:
Last Name:DATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 HARTSHORN DR
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-1916
Mailing Address - Country:US
Mailing Address - Phone:718-284-5500
Mailing Address - Fax:718-284-5600
Practice Address - Street 1:2848 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-4106
Practice Address - Country:US
Practice Address - Phone:718-284-5500
Practice Address - Fax:718-284-5600
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02282231Medicaid