Provider Demographics
NPI:1710555115
Name:MOORE, ETHAN EMBREY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:EMBREY
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 1:4216 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3093
Mailing Address - Country:US
Mailing Address - Phone:601-268-3333
Mailing Address - Fax:601-268-6666
Practice Address - Street 1:4216 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3093
Practice Address - Country:US
Practice Address - Phone:601-268-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4212-211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice