Provider Demographics
NPI:1467983205
Name:DR TANISHA R MOORE DDS, INC DBA HOMETOWN DDS
Entity Type:Organization
Organization Name:DR TANISHA R MOORE DDS, INC DBA HOMETOWN DDS
Other - Org Name:HOMETOWN DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-399-4470
Mailing Address - Street 1:221 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2666
Mailing Address - Country:US
Mailing Address - Phone:937-399-4470
Mailing Address - Fax:
Practice Address - Street 1:221 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2666
Practice Address - Country:US
Practice Address - Phone:937-399-4470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty