Provider Demographics
NPI:1760889299
Name:MOSBY, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MOSBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 COTTON DEPOT LN APT 643
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-7801
Mailing Address - Country:US
Mailing Address - Phone:281-658-9327
Mailing Address - Fax:
Practice Address - Street 1:225 E RENFRO ST STE 109
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3958
Practice Address - Country:US
Practice Address - Phone:817-717-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35052122300000X
390200000X
TN102711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program