Ethan D. Moulton, D.D.S.,M.S.

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

D-4093-PE Issued in ID

Practice address

2375 E Sunnyside Rd Ste I
Idaho Falls, ID 83404-8281

Phone

(208) 522-6683

Fax

(208) 552-3085

NPI assigned

Jun 13, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Moulton Periodontics, PLLC

  • Dental Clinic/Center
  • Idaho Falls, ID
  • NPI 1104085935
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150156800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1189900800000",
    "number": "1740222579",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2375 E SUNNYSIDE RD STE I",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048281",
            "telephone_number": "208-522-6683",
            "fax_number": "208-552-3085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2375 E SUNNYSIDE RD STE I",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048281",
            "telephone_number": "208-522-6683",
            "fax_number": "208-552-3085"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MOULTON",
        "first_name": "ETHAN",
        "middle_name": "D.",
        "credential": "D.D.S.,M.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-13",
        "last_updated": "2007-09-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "OK",
            "license": "5588",
            "primary": false
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "ID",
            "license": "D-4093-PE",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Daryl A Moss, D.C.
• Renee Marie Moss, CMT
• Sheila Moss, FNP-C
• Moulton Periodontics, PLLC
• Barbara J Moulton
• Mountain Care Pharmacy Idaho
• Mountain Crest Foot and Ankle PA
• Mountain Falls Medical LLC
• Mountain Falls Quick Care
• Mountain River Mental Health

• Periodontics in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Periodontics in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.