Provider Demographics
NPI:1912290446
Name:MOSHER, TIMOTHY (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:MOSHER
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 1:150 E 200 N STE H
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4036
Mailing Address - Country:US
Mailing Address - Phone:435-753-9470
Mailing Address - Fax:
Practice Address - Street 1:150 E 200 N STE H
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4036
Practice Address - Country:US
Practice Address - Phone:435-753-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86789141223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics