Provider Demographics
NPI:1649633595
Name:MORENO, COLLEEN MARIE JAVIER (DDS)
Entity type:Individual
Prefix:DR
First Name:COLLEEN MARIE
Middle Name:JAVIER
Last Name:MORENO
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 1:7704 ELGAR ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151
Mailing Address - Country:US
Mailing Address - Phone:571-276-4334
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10621122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist