Provider Demographics
NPI:1578624276
Name:MOORE, CHARLES WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615
Mailing Address - Country:US
Mailing Address - Phone:813-886-2527
Mailing Address - Fax:813-887-3225
Practice Address - Street 1:6025 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615
Practice Address - Country:US
Practice Address - Phone:813-886-2527
Practice Address - Fax:813-887-3225
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice