Provider Demographics
NPI:1427435809
Name:HAITHAM MOSLY, DMD, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:HAITHAM MOSLY, DMD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD/PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAITHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-797-0406
Mailing Address - Street 1:1740 SANTA CLARA DR
Mailing Address - Street 2:SUITE 100-B
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 SANTA CLARA DR
Practice Address - Street 2:SUITE 100-B
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2921
Practice Address - Country:US
Practice Address - Phone:916-797-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty