Healthcare Provider Details

I. General information

NPI: 1144528134
Provider Name (Legal Business Name): RANDALL A. MOORE, DMD,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MILBANK AVE
GREENWICH CT
06830-6616
US

IV. Provider business mailing address

141 MILBANK AVE
GREENWICH CT
06830-6616
US

V. Phone/Fax

Practice location:
  • Phone: 203-869-3377
  • Fax:
Mailing address:
  • Phone: 203-869-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number010308
License Number StateCT

VIII. Authorized Official

Name: DR. RANDALL A. MOORE
Title or Position: OWNER
Credential: DMD
Phone: 203-869-3377