Provider Demographics
NPI:1104316801
Name:MOUA, CHIA WAM (DDS)
Entity type:Individual
Prefix:DR
First Name:CHIA
Middle Name:WAM
Last Name:MOUA
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 1:1770 BLUEWATER LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6236
Mailing Address - Country:US
Mailing Address - Phone:612-810-0978
Mailing Address - Fax:
Practice Address - Street 1:1670 BEAM AVE STE 204
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1227
Practice Address - Country:US
Practice Address - Phone:651-925-8416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice