Provider Demographics
NPI:1720570377
Name:MOSKOVIC, ETHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:MOSKOVIC
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 1:73 MURIEL AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1810
Mailing Address - Country:US
Mailing Address - Phone:516-660-6367
Mailing Address - Fax:
Practice Address - Street 1:324 ELMIRA RD STE 200
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5106
Practice Address - Country:US
Practice Address - Phone:607-273-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060576122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist