Provider Demographics
NPI:1144415597
Name:MORA, JUAN CARLOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:MORA
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 1:22 MYSTIC LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1942
Mailing Address - Country:US
Mailing Address - Phone:610-240-7730
Mailing Address - Fax:610-240-7733
Practice Address - Street 1:22 MYSTIC LN
Practice Address - Street 2:SUITE A
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1942
Practice Address - Country:US
Practice Address - Phone:610-240-7730
Practice Address - Fax:610-240-7733
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0371231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice