Basic Information
| Provider Information | |||||||||
| NPI: | 1659433738 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS MOORHEAD& ROSS DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1140 | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078743731 | ||||||||
| FaxNumber: | 9078743531 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078743731 | ||||||||
| FaxNumber: | 9078743531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOORHEAD | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9078743731 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 570 | AK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 550 | AK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DD0550 DD0570 | 05 | AL | MEDICAID |