Provider Demographics
NPI:1356439061
Name:MOSS, RICHARD BRADLEY (DDS, PLLC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRADLEY
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS, PLLC
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PLLC
Mailing Address - Street 1:1011 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5305
Mailing Address - Country:US
Mailing Address - Phone:817-488-6513
Mailing Address - Fax:
Practice Address - Street 1:1011 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5305
Practice Address - Country:US
Practice Address - Phone:817-488-6513
Practice Address - Fax:817-488-0487
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX165261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD16526OtherBC/BS
TX731666OtherUNITED CONCORDIA