Provider Demographics
NPI:1871568386
Name:MOITOSO, EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MOITOSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 BOBCAT VILLAGE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-8972
Mailing Address - Country:US
Mailing Address - Phone:941-429-6558
Mailing Address - Fax:941-429-6559
Practice Address - Street 1:3015 BOBCAT VILLAGE CENTER RD
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-8972
Practice Address - Country:US
Practice Address - Phone:941-429-6558
Practice Address - Fax:941-429-6559
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-19
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075844200Medicaid