Provider Demographics
NPI:1740284769
Name:MOIST, RICHARD R (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:MOIST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2549
Mailing Address - Country:US
Mailing Address - Phone:417-881-5155
Mailing Address - Fax:
Practice Address - Street 1:2122 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2549
Practice Address - Country:US
Practice Address - Phone:417-881-5155
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104311223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics