Healthcare Provider Details

I. General information

NPI: 1972112969
Provider Name (Legal Business Name): MARIYA MOORE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 POST RD
FAIRFIELD CT
06824-5938
US

IV. Provider business mailing address

175 JAFFREY ST
BROOKLYN NY
11235-3022
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-6851
  • Fax:
Mailing address:
  • Phone: 347-224-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number062778
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02925100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13620
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: