Provider Demographics
NPI:1609860972
Name:MOORE-MARTIN, STACIE M (DMD)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:M
Last Name:MOORE-MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:STACIE
Other - Middle Name:M
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:27 TURKEY CRK
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:KY
Mailing Address - Zip Code:41645-6403
Mailing Address - Country:US
Mailing Address - Phone:606-285-9444
Mailing Address - Fax:606-285-9449
Practice Address - Street 1:27 TURKEY CRK
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:KY
Practice Address - Zip Code:41645-6403
Practice Address - Country:US
Practice Address - Phone:606-285-9444
Practice Address - Fax:606-285-9449
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6001740Medicaid