Provider Demographics
NPI:1336331230
Name:MOORE, DWAYNE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1845 S EVANSTON ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5718
Mailing Address - Country:US
Mailing Address - Phone:202-494-5194
Mailing Address - Fax:303-923-3721
Practice Address - Street 1:3210 E WOODMEN RD
Practice Address - Street 2:#200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3588
Practice Address - Country:US
Practice Address - Phone:719-358-6998
Practice Address - Fax:719-358-6952
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO93331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice