Provider Demographics
NPI:1447894795
Name:MOSS, RENICKE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:RENICKE
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-4071
Mailing Address - Country:US
Mailing Address - Phone:469-569-4194
Mailing Address - Fax:
Practice Address - Street 1:3302 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2013
Practice Address - Country:US
Practice Address - Phone:214-828-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist