Provider Demographics
NPI:1114914066
Name:MOORE, HAZEL E (DDS)
Entity Type:Individual
Prefix:DR
First Name:HAZEL
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5822 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1824
Mailing Address - Country:US
Mailing Address - Phone:262-681-2085
Mailing Address - Fax:
Practice Address - Street 1:4536 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5917
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-653-2218
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3267-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33462500Medicaid