Provider Demographics
NPI:1619056694
Name:MOORE, JAMES H (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:H
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 1:925 2ND AVE NO
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661
Mailing Address - Country:US
Mailing Address - Phone:208-642-4782
Mailing Address - Fax:208-642-1748
Practice Address - Street 1:925 2ND AVE NO
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661
Practice Address - Country:US
Practice Address - Phone:208-642-4782
Practice Address - Fax:208-642-1748
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist