Healthcare Provider Details

I. General information

NPI: 1720158470
Provider Name (Legal Business Name): BRENT ALLEN MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 OLIO RD SUITE #100
FISHERS IN
46037-7677
US

IV. Provider business mailing address

14575 LANSING PLACE
FISHERS IN
46038
US

V. Phone/Fax

Practice location:
  • Phone: 317-348-1354
  • Fax: 866-511-4151
Mailing address:
  • Phone: 317-679-8207
  • Fax: 866-511-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12010751A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: