Provider Demographics
NPI:1598809899
Name:MOE, LARRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:MOE
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 1:20899 SPANISH GRANT DR STE A
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9500
Mailing Address - Country:US
Mailing Address - Phone:209-533-2225
Mailing Address - Fax:209-533-3325
Practice Address - Street 1:20899 SPANISH GRANT DR STE A
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-9500
Practice Address - Country:US
Practice Address - Phone:209-533-2225
Practice Address - Fax:209-533-3325
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB24315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist