Provider Demographics
NPI:1265743488
Name:MORALES, EDDIE (DDS)
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:MORALES
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 1:2933 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2626
Mailing Address - Country:US
Mailing Address - Phone:414-282-2642
Mailing Address - Fax:
Practice Address - Street 1:2933 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2626
Practice Address - Country:US
Practice Address - Phone:414-282-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7160-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN190001065Medicare PIN