Provider Demographics
NPI:1255321212
Name:MOORE, DOUGLAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
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 1:1134 VINE ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2561
Mailing Address - Country:US
Mailing Address - Phone:805-238-1441
Mailing Address - Fax:805-238-3836
Practice Address - Street 1:1134 VINE ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2561
Practice Address - Country:US
Practice Address - Phone:805-238-1441
Practice Address - Fax:805-238-3836
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA477581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice