Healthcare Provider Details

I. General information

NPI: 1205968120
Provider Name (Legal Business Name): MOORE DENTAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 CAVALIER BLVD 300
FLORENCE KY
41042
US

IV. Provider business mailing address

59 CAVALIER BLVD 300
FLORENCE KY
41042
US

V. Phone/Fax

Practice location:
  • Phone: 859-525-0507
  • Fax: 859-525-0610
Mailing address:
  • Phone: 859-525-0507
  • Fax: 859-525-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARTIN JOSEPH MOORE
Title or Position: PRES
Credential:
Phone: 859-371-4422