Provider Demographics
NPI:1225306483
Name:MOORE, MARTIN JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOSEPH
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6961 BURLINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042
Mailing Address - Country:US
Mailing Address - Phone:859-371-4422
Mailing Address - Fax:859-282-5482
Practice Address - Street 1:6961 BURLINGTON PIKE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-371-4422
Practice Address - Fax:859-282-5482
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61081223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061082Medicaid