Provider Demographics
NPI:1720165954
Name:MOORE, JOHN GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
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 1:1160 JOHNSON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1487
Mailing Address - Country:US
Mailing Address - Phone:304-842-2361
Mailing Address - Fax:
Practice Address - Street 1:1160 JOHNSON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1487
Practice Address - Country:US
Practice Address - Phone:304-842-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137163000Medicaid
WA94661OtherUNITED CONCORDIA