Provider Demographics
NPI:1427162932
Name:MOSES, JACKSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JACKSON
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:SUITE 238
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6410
Mailing Address - Country:US
Mailing Address - Phone:949-364-0220
Mailing Address - Fax:949-582-0563
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 238
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6410
Practice Address - Country:US
Practice Address - Phone:949-364-0220
Practice Address - Fax:949-582-0563
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA211741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery