Provider Demographics
NPI:1053452250
Name:MOORE, DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-641-3212
Mailing Address - Fax:702-459-0320
Practice Address - Street 1:650 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5382
Practice Address - Country:US
Practice Address - Phone:702-641-3212
Practice Address - Fax:702-459-0320
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV 99072080A0000X
NV9907208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053452250Medicaid
NV002018572Medicaid
NVGD434ZMedicare PIN