Provider Demographics
NPI:1497806756
Name:MOORE, MICHAEL GAVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GAVIN
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 1:350 ALBERTA DR
Mailing Address - Street 2:101
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1855
Mailing Address - Country:US
Mailing Address - Phone:716-835-1670
Mailing Address - Fax:716-862-9844
Practice Address - Street 1:350 ALBERTA DR
Practice Address - Street 2:101
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1855
Practice Address - Country:US
Practice Address - Phone:716-835-1670
Practice Address - Fax:716-862-9844
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0502501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice