Provider Demographics
NPI:1083079164
Name:DAVID E MOORE DDS, PS
Entity Type:Organization
Organization Name:DAVID E MOORE DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE CORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-457-4532
Mailing Address - Street 1:11 N 11TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3085
Mailing Address - Country:US
Mailing Address - Phone:509-457-4532
Mailing Address - Fax:509-453-0175
Practice Address - Street 1:11 N 11TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3085
Practice Address - Country:US
Practice Address - Phone:509-457-4532
Practice Address - Fax:509-453-0175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60381727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029904Medicaid