Provider Demographics
NPI:1891866893
Name:MOORE, MELVIN GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:GREGORY
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 1:4723 N ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3886
Mailing Address - Country:US
Mailing Address - Phone:423-283-0511
Mailing Address - Fax:423-283-0899
Practice Address - Street 1:4723 N ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-3886
Practice Address - Country:US
Practice Address - Phone:423-283-0511
Practice Address - Fax:423-283-0899
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice