Provider Demographics
NPI:1790825339
Name:MOORE, JENNIFER ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:9 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-2201
Mailing Address - Country:US
Mailing Address - Phone:516-935-3083
Mailing Address - Fax:
Practice Address - Street 1:3000 HEMPSTEAD TPKE
Practice Address - Street 2:SUITE 101
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1381
Practice Address - Country:US
Practice Address - Phone:516-735-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0498081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice