Provider Demographics
NPI:1467563262
Name:MOORE, MARLON K (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:K
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 EASTCHESTER RD STE 230
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2335
Mailing Address - Country:US
Mailing Address - Phone:718-518-1776
Mailing Address - Fax:718-918-1776
Practice Address - Street 1:1776 EASTCHESTER RD STE 230
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2335
Practice Address - Country:US
Practice Address - Phone:718-518-1776
Practice Address - Fax:718-918-1776
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01815892Medicaid
NY01815892Medicaid
NYU71531Medicare UPIN