Provider Demographics
NPI:1669671558
Name:MOORE, ADAM (DDS)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:MOORE
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 1:143 GAULT RD
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:TX
Mailing Address - Zip Code:78606-2598
Mailing Address - Country:US
Mailing Address - Phone:832-799-9862
Mailing Address - Fax:
Practice Address - Street 1:1705 MARK WOOD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-8455
Practice Address - Country:US
Practice Address - Phone:281-689-5266
Practice Address - Fax:883-798-5508
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK71541223G0001X
TX233461223P0221X
PADS0384241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2803256-01Medicaid