Healthcare Provider Details

I. General information

NPI: 1619056694
Provider Name (Legal Business Name): JAMES H MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 2ND AVE NO
PAYETTE ID
83661
US

IV. Provider business mailing address

925 2ND AVE NO
PAYETTE ID
83661
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4782
  • Fax: 208-642-1748
Mailing address:
  • Phone: 208-642-4782
  • Fax: 208-642-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3950
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: