Provider Demographics
NPI:1952574964
Name:MOORE, GWENDOLYN F (DMD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:F
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 1:424 JOANN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704
Mailing Address - Country:US
Mailing Address - Phone:662-931-1022
Mailing Address - Fax:
Practice Address - Street 1:4233 HIGHWAY 8 EAST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2950-96122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660163Medicaid