Healthcare Provider Details

I. General information

NPI: 1336311414
Provider Name (Legal Business Name): MARK MOORE DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 WINDWARD LN
GAINESVILLE GA
30501-7418
US

IV. Provider business mailing address

2048 WINDWARD LN
GAINESVILLE GA
30501-7418
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-7888
  • Fax:
Mailing address:
  • Phone: 770-297-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN011706
License Number StateGA

VIII. Authorized Official

Name: DR. MARK PHILLIP MOORE
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-297-7888