Provider Demographics
NPI:1578918595
Name:MOORE, LOVE
Entity Type:Individual
Prefix:
First Name:LOVE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 WOOTEN BLVD SW STE F
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4464
Mailing Address - Country:US
Mailing Address - Phone:252-291-4300
Mailing Address - Fax:252-291-2337
Practice Address - Street 1:2401 WOOTEN BLVD SW STE F
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4464
Practice Address - Country:US
Practice Address - Phone:252-291-4300
Practice Address - Fax:252-291-2337
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC108621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty