Provider Demographics
NPI:1003996760
Name:MOORES, JACK FRANK III (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:FRANK
Last Name:MOORES
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42051 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-3143
Mailing Address - Country:US
Mailing Address - Phone:586-323-7700
Mailing Address - Fax:586-323-7707
Practice Address - Street 1:42051 MOUND RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3143
Practice Address - Country:US
Practice Address - Phone:586-323-7700
Practice Address - Fax:586-323-7707
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010164231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3111522Medicaid
MIU50526Medicare UPIN
MI3111522Medicaid