Provider Demographics
NPI:1639238264
Name:MOORE, PAUL T (DMD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:MOORE
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 1:306 SOUTH SHADY AVE.
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:VA
Mailing Address - Zip Code:24236
Mailing Address - Country:US
Mailing Address - Phone:276-475-5116
Mailing Address - Fax:276-475-5665
Practice Address - Street 1:306 SOUTH SHADY AVE.
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:VA
Practice Address - Zip Code:24236
Practice Address - Country:US
Practice Address - Phone:276-475-5116
Practice Address - Fax:276-475-5665
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist