Provider Demographics
NPI:1861628745
Name:MOORE, MARK TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TIMOTHY
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 1:806 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9508
Mailing Address - Country:US
Mailing Address - Phone:336-454-1192
Mailing Address - Fax:336-454-1193
Practice Address - Street 1:806 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-9508
Practice Address - Country:US
Practice Address - Phone:336-454-1192
Practice Address - Fax:336-454-1193
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics