Provider Demographics
NPI:1740297068
Name:MOORE, BARTLEY REED (DDS)
Entity type:Individual
Prefix:DR
First Name:BARTLEY
Middle Name:REED
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 1:1225 N PIKE ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-2629
Mailing Address - Country:US
Mailing Address - Phone:304-265-1800
Mailing Address - Fax:304-265-3468
Practice Address - Street 1:1225 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1048
Practice Address - Country:US
Practice Address - Phone:304-265-1800
Practice Address - Fax:304-265-3468
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4003007000Medicaid