Provider Demographics
NPI:1376656819
Name:MOORE, CHARLES WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALTER
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 1:601 HIDDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3307
Mailing Address - Country:US
Mailing Address - Phone:636-928-3302
Mailing Address - Fax:
Practice Address - Street 1:1319 CAULKS HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-6863
Practice Address - Country:US
Practice Address - Phone:636-441-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist