Provider Demographics
NPI:1275690323
Name:MOORE, KEVIN LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S 2ND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-2444
Mailing Address - Country:US
Mailing Address - Phone:814-226-6321
Mailing Address - Fax:814-226-6353
Practice Address - Street 1:160 S 2ND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-2444
Practice Address - Country:US
Practice Address - Phone:814-226-6321
Practice Address - Fax:814-226-6353
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022522-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice