Provider Demographics
NPI:1265513378
Name:MOORE-EBHOHIMEN, DENISE (DDS)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:MOORE-EBHOHIMEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5256 ARMOUR RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5037
Mailing Address - Country:US
Mailing Address - Phone:706-653-7668
Mailing Address - Fax:706-653-7669
Practice Address - Street 1:5256 ARMOUR RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5037
Practice Address - Country:US
Practice Address - Phone:706-653-7668
Practice Address - Fax:706-653-7669
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA125211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9181770OtherDORAL
GA100674OtherAVESIS
GA0015637OtherASSURANT
GA600-25826OtherBLUE CROSS BLUE SHIELD AL
GA00965313AMedicaid
GA01419459OtherUNITED CONCORDIA