Healthcare Provider Details

I. General information

NPI: 1184643082
Provider Name (Legal Business Name): MICHAEL RALPH MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 BLANDING BLVD STE 6B
ORANGE PARK FL
32073-5065
US

IV. Provider business mailing address

7146 FITZPATRICK LN
JACKSONVILLE FL
32226-2220
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-5950
  • Fax: 904-276-5359
Mailing address:
  • Phone: 904-757-3330
  • Fax: 904-757-6265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN7308
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: