Healthcare Provider Details

I. General information

NPI: 1598809899
Provider Name (Legal Business Name): LARRY MOE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20899 SPANISH GRANT DR STE A
SONORA CA
95370-9500
US

IV. Provider business mailing address

20899 SPANISH GRANT DR STE A
SONORA CA
95370-9500
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-2225
  • Fax: 209-533-3325
Mailing address:
  • Phone: 209-533-2225
  • Fax: 209-533-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberB24315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: