Provider Demographics
NPI:1114470705
Name:RANDOLPH S MOORE DMD PC
Entity Type:Organization
Organization Name:RANDOLPH S MOORE DMD PC
Other - Org Name:SMILE MORE DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONDOLPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-945-5369
Mailing Address - Street 1:4470 COMMERCE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7510
Mailing Address - Country:US
Mailing Address - Phone:770-945-5368
Mailing Address - Fax:770-945-2896
Practice Address - Street 1:4470 COMMERCE DR
Practice Address - Street 2:SUITE B
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-7510
Practice Address - Country:US
Practice Address - Phone:770-945-5368
Practice Address - Fax:770-945-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0112881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty