Provider Demographics
NPI:1952498842
Name:MOSLEY, NICHOLAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:MOSLEY
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 1:6118 COVINGTON HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3530
Mailing Address - Country:US
Mailing Address - Phone:770-593-8249
Mailing Address - Fax:
Practice Address - Street 1:6118 COVINGTON HWY
Practice Address - Street 2:SUITE E
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3530
Practice Address - Country:US
Practice Address - Phone:770-593-8249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0099551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00348884MMedicaid