Provider Demographics
NPI:1245302918
Name:MOORE, CHARLES ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANDREW
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 1:5390 FONTENOY CT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-4700
Mailing Address - Country:US
Mailing Address - Phone:770-840-9889
Mailing Address - Fax:
Practice Address - Street 1:5462 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3239
Practice Address - Country:US
Practice Address - Phone:404-299-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00677311AMedicaid