Provider Demographics
NPI:1578608238
Name:MOORE, TANISHA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:TANISHA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TANISHA
Other - Middle Name:R
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
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:937-399-3338
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8087122300000X
OH23622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1632300125Medicaid