Provider Demographics
NPI:1982789566
Name:MOELLER, GARY A (DDS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MOELLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2247 NORTH JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801
Mailing Address - Country:US
Mailing Address - Phone:907-789-0619
Mailing Address - Fax:907-789-7004
Practice Address - Street 1:2247 NORTH JORDAN AVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-789-0619
Practice Address - Fax:907-789-7004
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK04611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice