Provider Demographics
NPI:1104208594
Name:MOORE DENTAL AT LEWIS CENTER
Entity Type:Organization
Organization Name:MOORE DENTAL AT LEWIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-603-0236
Mailing Address - Street 1:6421 PULLMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-7377
Mailing Address - Country:US
Mailing Address - Phone:740-548-5100
Mailing Address - Fax:
Practice Address - Street 1:6421 PULLMAN DR
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-7377
Practice Address - Country:US
Practice Address - Phone:740-548-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.023482261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental