Provider Demographics
NPI:1427183763
Name:MORIARITY, JOHN REX (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:REX
Last Name:MORIARITY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 STATE ST
Mailing Address - Street 2:PO BOX 368
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-9179
Mailing Address - Country:US
Mailing Address - Phone:231-582-8000
Mailing Address - Fax:231-582-6853
Practice Address - Street 1:830 STATE ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-9179
Practice Address - Country:US
Practice Address - Phone:231-582-8000
Practice Address - Fax:231-582-6853
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist