Provider Demographics
NPI:1336271550
Name:MOFFETT, WESLEY B (DMD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:B
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35212-2445
Mailing Address - Country:US
Mailing Address - Phone:205-592-2255
Mailing Address - Fax:205-592-3352
Practice Address - Street 1:5528 1ST AVE N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35212-2445
Practice Address - Country:US
Practice Address - Phone:205-592-2255
Practice Address - Fax:205-592-3352
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51539328OtherBCBSANNISTON
AL009942020Medicaid
AL009938614Medicaid
AL009938612Medicaid
AL51539329OtherBCBSHEFLIN
AL51539350OtherBCBSTALLADEGA
AL009938613Medicaid