Provider Demographics
NPI:1619906492
Name:MORENO, MICHAEL LEONOWICH (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEONOWICH
Last Name:MORENO
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 1:10312 HICKORY RIDGE RD
Mailing Address - Street 2:APT 226
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4615
Mailing Address - Country:US
Mailing Address - Phone:410-992-6798
Mailing Address - Fax:
Practice Address - Street 1:7939 HONEYGO BLVD
Practice Address - Street 2:SUITE 227
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4931
Practice Address - Country:US
Practice Address - Phone:410-931-0250
Practice Address - Fax:410-931-4876
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135891223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics