Healthcare Provider Details

I. General information

NPI: 1215139464
Provider Name (Legal Business Name): W.JIM MOORE, JR. D.D.S.,LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 S OLIVE ST
PINE BLUFF AR
71603-5438
US

IV. Provider business mailing address

3024 S OLIVE ST
PINE BLUFF AR
71603-5438
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-2650
  • Fax: 870-536-3820
Mailing address:
  • Phone: 870-536-2650
  • Fax: 870-536-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2165
License Number StateAR

VIII. Authorized Official

Name: DR. W. JIM MOORE JR.
Title or Position: OWNER
Credential: D.D.S., M.S.D.
Phone: 870-536-2650