Provider Demographics
NPI:1851511356
Name:MOORE, WENDY MIRANDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:MIRANDA
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9449 GROVER DR
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-7076
Mailing Address - Country:US
Mailing Address - Phone:540-775-5774
Mailing Address - Fax:540-775-6538
Practice Address - Street 1:9449 GROVER DR
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-7076
Practice Address - Country:US
Practice Address - Phone:540-775-5774
Practice Address - Fax:540-775-6538
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010088881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice