Provider Demographics
NPI:1164532370
Name:MOORE, HAL RAYMOND IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:HAL
Middle Name:RAYMOND
Last Name:MOORE
Suffix:IV
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 1:4102 PINION DR
Mailing Address - Street 2:10TH MDG
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-5192
Mailing Address - Fax:719-333-5633
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:10TH MDG
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5192
Practice Address - Fax:719-333-5633
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist