Provider Demographics
NPI:1982647624
Name:MOSE, JOHN DEE III (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DEE
Last Name:MOSE
Suffix:III
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 1:5602 SOUTH MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145
Mailing Address - Country:US
Mailing Address - Phone:918-294-9750
Mailing Address - Fax:918-249-1265
Practice Address - Street 1:5602 SOUTH MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145
Practice Address - Country:US
Practice Address - Phone:918-294-9750
Practice Address - Fax:918-249-1265
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5674122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200015470AMedicaid