Provider Demographics
NPI:1295049898
Name:MOELLER, TERA M (DDS)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:M
Last Name:MOELLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1765
Mailing Address - Country:US
Mailing Address - Phone:513-932-1370
Mailing Address - Fax:513-932-0814
Practice Address - Street 1:736 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1765
Practice Address - Country:US
Practice Address - Phone:513-932-1370
Practice Address - Fax:513-932-0814
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist