Provider Demographics
NPI:1972725794
Name:MORAN, JACQUELINE B (RDH)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:B
Last Name:MORAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 WINDSOR LANE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464
Mailing Address - Country:US
Mailing Address - Phone:757-953-8547
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD # VA23511
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2803
Practice Address - Country:US
Practice Address - Phone:757-953-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402003200124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist