Provider Demographics
NPI:1376926154
Name:MASOUDIPOYA MOORE, KRISTEN ASHRAF (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ASHRAF
Last Name:MASOUDIPOYA 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 1:221 6TH AVE S APT H
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6664
Mailing Address - Country:US
Mailing Address - Phone:904-614-0651
Mailing Address - Fax:
Practice Address - Street 1:9109 BAYMEADOWS RD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1842
Practice Address - Country:US
Practice Address - Phone:904-731-4343
Practice Address - Fax:904-733-0816
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21266122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist