Provider Demographics
NPI:1801930532
Name:MOORE, SUSANNE REYNOLDS (DMD)
Entity type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:REYNOLDS
Last Name:MOORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 OLD FANNIN ROAD
Mailing Address - Street 2:SUITE 26
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-992-7972
Mailing Address - Fax:601-992-7972
Practice Address - Street 1:1149 OLD FANNIN RD
Practice Address - Street 2:SUITE 26
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047
Practice Address - Country:US
Practice Address - Phone:601-992-7972
Practice Address - Fax:601-992-7972
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3045981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice