Provider Demographics
NPI:1770674806
Name:MOORE, ALISA O (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:O
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
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Mailing Address - Street 1:PO BOX 310065
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31131-0065
Mailing Address - Country:US
Mailing Address - Phone:404-349-7777
Mailing Address - Fax:404-349-8459
Practice Address - Street 1:2440 FAIRBURN RD SW
Practice Address - Street 2:SUITE 301
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5256
Practice Address - Country:US
Practice Address - Phone:404-349-7777
Practice Address - Fax:404-349-8459
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA107311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry