Provider Demographics
NPI:1275615635
Name:MOORE, ROBERT L (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
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 1:1717 W 6TH
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074
Mailing Address - Country:US
Mailing Address - Phone:405-743-4664
Mailing Address - Fax:405-743-3366
Practice Address - Street 1:1717 W 6TH
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074
Practice Address - Country:US
Practice Address - Phone:405-743-4664
Practice Address - Fax:405-743-3366
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice