Provider Demographics
NPI:1902902208
Name:MOOSO, BRETT EDDIS (DDS,MS,PA)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:EDDIS
Last Name:MOOSO
Suffix:
Gender:M
Credentials:DDS,MS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6269
Mailing Address - Country:US
Mailing Address - Phone:208-522-4552
Mailing Address - Fax:208-522-4555
Practice Address - Street 1:1410 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6269
Practice Address - Country:US
Practice Address - Phone:208-522-4552
Practice Address - Fax:208-522-4555
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3029-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6083OtherBLUE CROSS PROVIDER NUMBE
ID000010012359OtherBLUE SHIELD PROVIDE NUMBE