Provider Demographics
NPI:1194737825
Name:MOONEY, ROSEANN T (DMD)
Entity type:Individual
Prefix:
First Name:ROSEANN
Middle Name:T
Last Name:MOONEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6032
Mailing Address - Country:US
Mailing Address - Phone:208-336-9333
Mailing Address - Fax:208-387-1951
Practice Address - Street 1:314 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6032
Practice Address - Country:US
Practice Address - Phone:208-336-9333
Practice Address - Fax:208-387-1951
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist