Provider Demographics
NPI:1417398256
Name:RYAN A MOORE DDS, PLLC
Entity Type:Organization
Organization Name:RYAN A MOORE DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-351-0368
Mailing Address - Street 1:8116 CANTRELL RD STE C
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-2502
Mailing Address - Country:US
Mailing Address - Phone:501-227-5200
Mailing Address - Fax:
Practice Address - Street 1:8116 CANTRELL RD STE C
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-2502
Practice Address - Country:US
Practice Address - Phone:501-227-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188398608Medicaid