Provider Demographics
NPI:1225695703
Name:MOORE, NICHOLAS JAY (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAY
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 1:947 WEEKS AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2675
Mailing Address - Country:US
Mailing Address - Phone:816-699-0732
Mailing Address - Fax:
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-868-8263
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019016638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019016638OtherMISSOURI PROFESSIONAL LICENSE