Basic Information
| Provider Information | |||||||||
| NPI: | 1952407504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSLY | ||||||||
| FirstName: | HAITHAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 CENTRAL PARK DR APT 3611 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956783530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512079660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6406 SUNRISE BLVD | ||||||||
| Address2: | |||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956105992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167271880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D12156 | MN | Y | Dental Providers | Dentist | 122300000X | 61008 | CA | N | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 9181169 | 01 | MN | U-CARE/DORAL | OTHER | 019170100 | 05 | MN | MEDICAID |