Provider Demographics
NPI:1477579308
Name:MOORE, GREGORY BARDIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BARDIN
Last Name:MOORE
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 1:595 CHAPEL HILLS DR.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920
Mailing Address - Country:US
Mailing Address - Phone:719-475-2511
Mailing Address - Fax:
Practice Address - Street 1:595 CHAPEL HILLS DR.
Practice Address - Street 2:SUITE 105
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-475-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1062341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice