Provider Demographics
NPI:1790970663
Name:MOELLER ZEVALLOS, SERGIO MAURICIO (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:MAURICIO
Last Name:MOELLER ZEVALLOS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:MAURICIO
Other - Middle Name:SERGIO
Other - Last Name:MOELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:2509 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6145
Mailing Address - Country:US
Mailing Address - Phone:734-662-7874
Mailing Address - Fax:734-662-1518
Practice Address - Street 1:2509 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6145
Practice Address - Country:US
Practice Address - Phone:734-662-7874
Practice Address - Fax:734-662-1518
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018235122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice