Provider Demographics
NPI:1972649952
Name:MOOS, RONALD (DDS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MOOS
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 1:328 FRANCES AVENUE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-0739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 N FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-0739
Practice Address - Country:US
Practice Address - Phone:920-533-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0445G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist