Provider Demographics
NPI:1447685953
Name:MOSER, SALLY VANESSA (DDS)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:VANESSA
Last Name:MOSER
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 1:3601 W. WILLIAM CANNON DR
Mailing Address - Street 2:BLDG 4, STE 500
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749
Mailing Address - Country:US
Mailing Address - Phone:512-892-0817
Mailing Address - Fax:512-899-2111
Practice Address - Street 1:3601 W. WILLIAM CANNON DR
Practice Address - Street 2:BLDG 4, STE 500
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749
Practice Address - Country:US
Practice Address - Phone:512-892-0817
Practice Address - Fax:512-899-2111
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA629021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice