Provider Demographics
NPI:1184643082
Name:MOORE, MICHAEL RALPH (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RALPH
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 1:7146 FITZPATRICK LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-2220
Mailing Address - Country:US
Mailing Address - Phone:904-757-3330
Mailing Address - Fax:904-757-6265
Practice Address - Street 1:410 BLANDING BLVD STE 6B
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5065
Practice Address - Country:US
Practice Address - Phone:904-276-5950
Practice Address - Fax:904-276-5359
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7308122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist