Provider Demographics
NPI:1740571421
Name:MOSS, WHITTAKER (DDS)
Entity Type:Individual
Prefix:DR
First Name:WHITTAKER
Middle Name:
Last Name:MOSS
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 1:1567 N EASTMAN RD STE 16
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2680
Mailing Address - Country:US
Mailing Address - Phone:423-246-9231
Mailing Address - Fax:423-246-9232
Practice Address - Street 1:1567 N EASTMAN RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2683
Practice Address - Country:US
Practice Address - Phone:423-246-9231
Practice Address - Fax:865-983-9925
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92681223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist