Provider Demographics
NPI:1881684587
Name:MOYER, DAVID J (DDS,MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MOYER
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LONG CREEK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2425
Mailing Address - Country:US
Mailing Address - Phone:207-772-4063
Mailing Address - Fax:207-772-8641
Practice Address - Street 1:20 LONG CREEK DR
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2425
Practice Address - Country:US
Practice Address - Phone:207-772-4063
Practice Address - Fax:207-772-8641
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME126841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3074500099Medicaid
MOMM3070Medicare ID - Type Unspecified
T83769Medicare UPIN