Provider Demographics
NPI:1659831618
Name:MOOREHEAD, TATYANIA
Entity Type:Individual
Prefix:
First Name:TATYANIA
Middle Name:
Last Name:MOOREHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 PROSPECT LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8164
Mailing Address - Country:US
Mailing Address - Phone:704-968-6558
Mailing Address - Fax:
Practice Address - Street 1:636 CROWN POINTE DR STE 105
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4994
Practice Address - Country:US
Practice Address - Phone:803-329-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC11717122300000X
SC9963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program