Provider Demographics
NPI:1093373326
Name:MOORE, MICHAEL THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 RUHL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-2530
Mailing Address - Country:US
Mailing Address - Phone:814-602-1005
Mailing Address - Fax:
Practice Address - Street 1:2606 CAUGHEY RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-2148
Practice Address - Country:US
Practice Address - Phone:814-833-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist