Healthcare Provider Details

I. General information

NPI: 1376522979
Provider Name (Legal Business Name): GARY N MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 STAR RANCH RD
COLORADO SPRINGS CO
80906-5980
US

IV. Provider business mailing address

3695 STAR RANCH RD
COLORADO SPRINGS CO
80906-5980
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-7979
  • Fax: 719-597-8084
Mailing address:
  • Phone: 719-597-7979
  • Fax: 719-597-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8930
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3216
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8585
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: