Provider Demographics
NPI:1700576113
Name:ELEMENTAL DENTAL - SONYA R. MOESLE DDS, LLC
Entity Type:Organization
Organization Name:ELEMENTAL DENTAL - SONYA R. MOESLE DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MOESLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-964-3500
Mailing Address - Street 1:686 CORYLUS DR
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7628
Mailing Address - Country:US
Mailing Address - Phone:740-964-3500
Mailing Address - Fax:740-964-3502
Practice Address - Street 1:686 CORYLUS DR
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7628
Practice Address - Country:US
Practice Address - Phone:740-964-3500
Practice Address - Fax:740-964-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689975005OtherINDIVIDUAL NPI
OH30.020362OtherOHIO DENTAL LICENSE NUMBER