Provider Demographics
NPI:1336819267
Name:MOE, ERIC DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DAVID
Last Name:MOE
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 1:120 HENNEPIN AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1909
Mailing Address - Country:US
Mailing Address - Phone:701-540-2833
Mailing Address - Fax:
Practice Address - Street 1:14065 ESSEX AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6857
Practice Address - Country:US
Practice Address - Phone:952-423-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND146631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics