Provider Demographics
NPI:1174635221
Name:MORENO, CAROL LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LYNN
Last Name:MORENO
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 1:1205 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52776-9601
Mailing Address - Country:US
Mailing Address - Phone:319-627-2612
Mailing Address - Fax:319-627-2178
Practice Address - Street 1:1205 N COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52776-9601
Practice Address - Country:US
Practice Address - Phone:319-627-2612
Practice Address - Fax:319-627-2178
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA68991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1216853Medicaid