Provider Demographics
NPI:1124382957
Name:MOORE, JACOB GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GORDON
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10104 SADDLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-7290
Mailing Address - Country:US
Mailing Address - Phone:254-836-9595
Mailing Address - Fax:
Practice Address - Street 1:10104 SADDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-7290
Practice Address - Country:US
Practice Address - Phone:254-836-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice