Provider Demographics
NPI:1992755136
Name:MOSELEY, LYNNE MARIE (DDS)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:MARIE
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32364 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4218
Mailing Address - Country:US
Mailing Address - Phone:248-593-2995
Mailing Address - Fax:
Practice Address - Street 1:30021 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1509
Practice Address - Country:US
Practice Address - Phone:248-594-8777
Practice Address - Fax:248-594-9779
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010141181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4752030Medicaid
MID141180OtherBLUE CROSS