Provider Demographics
NPI:1972841781
Name:MOORE, JOHN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:113 N. WINTER ST.
Mailing Address - City:MIDWAY
Mailing Address - State:KY
Mailing Address - Zip Code:40347-0761
Mailing Address - Country:US
Mailing Address - Phone:859-846-4940
Mailing Address - Fax:859-846-4237
Practice Address - Street 1:113 N. WINTER ST.
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:KY
Practice Address - Zip Code:40347-0761
Practice Address - Country:US
Practice Address - Phone:859-846-4940
Practice Address - Fax:859-846-4237
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice