Provider Demographics
NPI:1992827174
Name:MOOS, JEFFREY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
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 1:1471 VALLEY ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-7899
Mailing Address - Country:US
Mailing Address - Phone:715-926-5323
Mailing Address - Fax:
Practice Address - Street 1:680 HEHLI WAY
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1639
Practice Address - Country:US
Practice Address - Phone:715-926-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31391223G0001X
MN113861223G0001X
IA84441223G0001X
IL190265831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice