Provider Demographics
NPI:1225022833
Name:MOORE, MARK PHILLIP (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILLIP
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:2048 WINDWARD LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7418
Mailing Address - Country:US
Mailing Address - Phone:770-297-7888
Mailing Address - Fax:770-297-7833
Practice Address - Street 1:2048 WINDWARD LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7418
Practice Address - Country:US
Practice Address - Phone:770-297-7888
Practice Address - Fax:770-297-7833
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0117061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery