Provider Demographics
NPI:1407902646
Name:MOORE, LYNDA M (DD,S)
Entity Type:Individual
Prefix:DR
First Name:LYNDA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:DD,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-0491
Mailing Address - Country:US
Mailing Address - Phone:423-775-0009
Mailing Address - Fax:423-775-0637
Practice Address - Street 1:391 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-1295
Practice Address - Country:US
Practice Address - Phone:423-775-0009
Practice Address - Fax:423-775-0637
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice