Provider Demographics
NPI:1477681922
Name:MOORE, MICHAEL MARCUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARCUS
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 1:8409 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7638
Mailing Address - Country:US
Mailing Address - Phone:702-254-6700
Mailing Address - Fax:
Practice Address - Street 1:8409 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7638
Practice Address - Country:US
Practice Address - Phone:702-254-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist