Provider Demographics
NPI:1437144292
Name:MOORE, DAISY KIT (DDS PA)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:KIT
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E STATE HIGHWAY 114
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5233
Mailing Address - Country:US
Mailing Address - Phone:817-410-7373
Mailing Address - Fax:817-416-9383
Practice Address - Street 1:1101 E STATE HIGHWAY 114
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5233
Practice Address - Country:US
Practice Address - Phone:817-410-7373
Practice Address - Fax:817-416-9383
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice