Provider Demographics
NPI:1619381431
Name:MOORE, NICHOLAS ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:MOORE
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 1:1013 LOCKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6001
Mailing Address - Country:US
Mailing Address - Phone:407-278-0934
Mailing Address - Fax:
Practice Address - Street 1:1013 LOCKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6001
Practice Address - Country:US
Practice Address - Phone:407-278-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20486122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist