Provider Demographics
NPI:1275532806
Name:MOORE, TOBIE DELTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:TOBIE
Middle Name:DELTON
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:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39669-1297
Mailing Address - Country:US
Mailing Address - Phone:601-888-3412
Mailing Address - Fax:601-888-3415
Practice Address - Street 1:643 HIGHWAY 61 S
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-1297
Practice Address - Country:US
Practice Address - Phone:601-888-3412
Practice Address - Fax:601-888-3415
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1696751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064270Medicaid