Provider Demographics
NPI:1376605196
Name:MOORE, WALKER B JR (D D S)
Entity Type:Individual
Prefix:DR
First Name:WALKER
Middle Name:B
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:SUITE #7
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:
Practice Address - Street 1:4687 ROCKBRIDGE RD
Practice Address - Street 2:SUITE #7
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4258
Practice Address - Country:US
Practice Address - Phone:404-296-9070
Practice Address - Fax:404-296-3456
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 76131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA 7613Medicaid