Individual
DR. BRETT EDDIS MOOSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.,M.S.,P.A.
Contact information
Practice address
1410 E 17TH ST, IDAHO FALLS, ID 83404-6269
(208) 522-4552
(208) 522-4555
Mailing address
1410 E 17TH ST, IDAHO FALLS, ID 83404-6269
(208) 522-4552
(208) 522-4555
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D-3029-OR
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010012359
BLUE SHIELD PROVIDE NUMBE
ID
01
—
6083
BLUE CROSS PROVIDER NUMBE
ID
Enumeration date
09/15/2006
Last updated
07/09/2007
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