Provider Demographics
NPI:1235307828
Name:MOON DORE, MANDIE SHEA (RDH,BS)
Entity Type:Individual
Prefix:MS
First Name:MANDIE
Middle Name:SHEA
Last Name:MOON DORE
Suffix:
Gender:F
Credentials:RDH,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S DENTON TAP RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3297
Mailing Address - Country:US
Mailing Address - Phone:469-635-1105
Mailing Address - Fax:972-316-6029
Practice Address - Street 1:120 S DENTON TAP RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3297
Practice Address - Country:US
Practice Address - Phone:469-635-1105
Practice Address - Fax:972-316-6029
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13777124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist