MEDICARE: DR. DAVID DWIGHT MOORE JR. D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223E0200X	Endodontics	59684	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R394	OTHER	MN	RESIDENT PERMIT

General Provider Information

NPI Number	:	1225204407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID DWIGHT MOORE JR. D.D.S.

Provider Business Mailing Address
First Line	:	235 N SAN MATEO DR
Second Line	:	SUITE 400
City	:	SAN MATEO
State	:	CA
Zip	:	94401-2621
Country	:	US
Telephone Number	:	650-340-0225
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 N SAN MATEO DR
Second Line	:	SUITE 400
City	:	SAN MATEO
State	:	CA
Zip	:	94401-2621
Country	:	US
Telephone Number	:	650-340-0225
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2008
Last Update Date	:	09/03/2010

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