Provider Demographics
NPI:1316395718
Name:GREGORY B. MOORE, DDS, PC
Entity Type:Organization
Organization Name:GREGORY B. MOORE, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BARDIN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-633-4028
Mailing Address - Street 1:559 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 319
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3651
Mailing Address - Country:US
Mailing Address - Phone:719-633-4028
Mailing Address - Fax:719-633-7890
Practice Address - Street 1:559 E PIKES PEAK AVE
Practice Address - Street 2:SUITE 319
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3651
Practice Address - Country:US
Practice Address - Phone:719-633-4028
Practice Address - Fax:719-633-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106234332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment