Provider Demographics
NPI:1952407504
Name:MOSLY, HAITHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAITHAM
Middle Name:
Last Name:MOSLY
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 1:751 CENTRAL PARK DR APT 3611
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3530
Mailing Address - Country:US
Mailing Address - Phone:651-207-9660
Mailing Address - Fax:
Practice Address - Street 1:6406 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-5992
Practice Address - Country:US
Practice Address - Phone:916-727-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12156122300000X
CA61008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9181169OtherU-CARE/DORAL
MN019170100Medicaid