Provider Demographics
NPI:1770607038
Name:MOSS, RONALD ALBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ALBERT
Last Name:MOSS
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 1:451 RUIN CREEK ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:252-492-3355
Mailing Address - Fax:252-492-9938
Practice Address - Street 1:451 RUIN CREEK ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536
Practice Address - Country:US
Practice Address - Phone:252-492-3355
Practice Address - Fax:252-492-9938
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996265Medicaid
1710904669OtherORGANIZATION NPI
1710904669OtherORGANIZATION NPI
NC2335869Medicare ID - Type Unspecified