Provider Demographics
NPI:1801472196
Name:MORENO, ANDREW FELICIANO ALFONSO (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW FELICIANO
Middle Name:ALFONSO
Last Name:MORENO
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 1:2206 PARKER CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2439
Mailing Address - Country:US
Mailing Address - Phone:805-390-7064
Mailing Address - Fax:
Practice Address - Street 1:15531 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2620
Practice Address - Country:US
Practice Address - Phone:818-894-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS104995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist