Provider Demographics
NPI:1629411814
Name:MOORE, KRISTY SHEREE (RDH)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:SHEREE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 LEMP AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2700
Mailing Address - Country:US
Mailing Address - Phone:314-814-8680
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:2220 LEMP AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2700
Practice Address - Country:US
Practice Address - Phone:314-814-8680
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011015049124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist