Provider Demographics
NPI:1477690246
Name:MOORE, BRENDA LESIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LESIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 34TH AVE. N.
Mailing Address - Street 2:A
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-2502
Mailing Address - Country:US
Mailing Address - Phone:615-327-4499
Mailing Address - Fax:615-327-0546
Practice Address - Street 1:908 34TH AVE. N.
Practice Address - Street 2:A
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-2502
Practice Address - Country:US
Practice Address - Phone:615-327-4499
Practice Address - Fax:615-327-0546
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN84551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440336Medicaid