Provider Demographics
NPI:1376745752
Name:MOORE, BECKY SUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:SUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 S CHEKSHANI CLF
Mailing Address - Street 2:
Mailing Address - City:NEW HARMONY
Mailing Address - State:UT
Mailing Address - Zip Code:84757-5136
Mailing Address - Country:US
Mailing Address - Phone:435-867-6190
Mailing Address - Fax:
Practice Address - Street 1:1933 S CHEKSHANI CLF
Practice Address - Street 2:
Practice Address - City:NEW HARMONY
Practice Address - State:UT
Practice Address - Zip Code:84757-5136
Practice Address - Country:US
Practice Address - Phone:435-867-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4550016-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist