MEDICARE: DR. GENE P MOORE DDS

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	1223G0001X	General Practice Dentistry	20419	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B20419 01	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1457424699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GENE P MOORE DDS

Provider Business Mailing Address
First Line	:	286 EUCLID AVE STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-3612
Country	:	US
Telephone Number	:	619-263-6683
Fax Number	:	619-263-0048

Provider Business Practice Location Address
First Line	:	286 EUCLID AVE STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-3612
Country	:	US
Telephone Number	:	619-263-6683
Fax Number	:	619-263-0048

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	06/21/2016

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