Provider Demographics
NPI:1407126683
Name:MOORE, GEORGE L (DDS,PC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SOLDIERS PASS RD
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-4782
Mailing Address - Country:US
Mailing Address - Phone:928-282-7871
Mailing Address - Fax:928-282-6470
Practice Address - Street 1:80 SOLDIERS PASS RD
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4782
Practice Address - Country:US
Practice Address - Phone:928-282-7871
Practice Address - Fax:928-282-6470
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ22051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice