Provider Demographics
NPI:1912911801
Name:MOORE, JOHN WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
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 1:1200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4102
Mailing Address - Country:US
Mailing Address - Phone:608-782-7374
Mailing Address - Fax:608-782-4111
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4102
Practice Address - Country:US
Practice Address - Phone:608-782-7374
Practice Address - Fax:608-782-4111
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5473-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice