Provider Demographics
NPI:1184842262
Name:MOORE, REGINALD IVORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:IVORY
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 1:19920 AVENIDA DESEO
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2210
Mailing Address - Country:US
Mailing Address - Phone:951-836-9181
Mailing Address - Fax:909-598-5995
Practice Address - Street 1:22675 ALESSANDRO BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8551
Practice Address - Country:US
Practice Address - Phone:951-571-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice