Provider Demographics
NPI:1962716399
Name:MARKS MOSS, SHANEKA S (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANEKA
Middle Name:S
Last Name:MARKS MOSS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHANEKA
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5103 MAGNA CARTA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5213
Mailing Address - Country:US
Mailing Address - Phone:972-352-6677
Mailing Address - Fax:972-352-6678
Practice Address - Street 1:5103 MAGNA CARTA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5213
Practice Address - Country:US
Practice Address - Phone:972-352-6677
Practice Address - Fax:972-352-6678
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist