Provider Demographics
NPI:1669734513
Name:MOORE, MILES CLINTON (DDS)
Entity type:Individual
Prefix:DR
First Name:MILES
Middle Name:CLINTON
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 1:725 W. BROOKHAVEN CR.
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:UM
Mailing Address - Phone:901-761-2210
Mailing Address - Fax:901-763-1092
Practice Address - Street 1:725 W BROOKHAVEN CIR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4503
Practice Address - Country:US
Practice Address - Phone:901-761-2210
Practice Address - Fax:901-763-1092
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice