Healthcare Provider Details

I. General information

NPI: 1487633756
Provider Name (Legal Business Name): THOMAS JOSEPH MORENO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 WARRIOR WAY
GROVETOWN GA
30813-8132
US

IV. Provider business mailing address

2054 WARRIOR WAY
GROVETOWN GA
30813-8132
US

V. Phone/Fax

Practice location:
  • Phone: 706-664-0744
  • Fax: 706-664-0747
Mailing address:
  • Phone: 706-664-0744
  • Fax: 706-664-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049476
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: