Provider Demographics
NPI:1043955057
Name:MORENO, HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:MORENO
Suffix:
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 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4374 ATLANTA HWY STE 109
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1849
Practice Address - Country:US
Practice Address - Phone:770-505-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1230231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice