Provider Demographics
NPI:1720387210
Name:MOSS, REOLA JIMPERSON (RDH)
Entity Type:Individual
Prefix:MISS
First Name:REOLA
Middle Name:JIMPERSON
Last Name:MOSS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 E 129TH ST
Mailing Address - Street 2:APT. 6N
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-1117
Mailing Address - Country:US
Mailing Address - Phone:212-939-1000
Mailing Address - Fax:212-939-2885
Practice Address - Street 1:16 W 137TH ST
Practice Address - Street 2:WP BLDG. 2ND FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1901
Practice Address - Country:US
Practice Address - Phone:212-939-1000
Practice Address - Fax:212-939-2885
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017591124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist