Provider Demographics
NPI:1629171160
Name:MOORMAN, BRIGHAM R (DDS)
Entity Type:Individual
Prefix:
First Name:BRIGHAM
Middle Name:R
Last Name:MOORMAN
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 1:1719 BARNESDALE WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2601
Mailing Address - Country:US
Mailing Address - Phone:404-879-0176
Mailing Address - Fax:
Practice Address - Street 1:400 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5980
Practice Address - Country:US
Practice Address - Phone:770-916-5028
Practice Address - Fax:678-302-7485
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374561223G0001X
GADN018561223G0001X
NY048628-11223G0001X
VA04014112401223G0001X
MA215051223G0001X
IN12010805A1223G0001X
AZ70251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9180712Medicaid
MA0205516Medicaid