Healthcare Provider Details

I. General information

NPI: 1770674806
Provider Name (Legal Business Name): ALISA O MOORE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 FAIRBURN RD SW SUITE 301
ATLANTA GA
30331-5256
US

IV. Provider business mailing address

PO BOX 310065
ATLANTA GA
31131-0065
US

V. Phone/Fax

Practice location:
  • Phone: 404-349-7777
  • Fax: 404-349-8459
Mailing address:
  • Phone: 404-349-7777
  • Fax: 404-349-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10731
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: