Healthcare Provider Details

I. General information

NPI: 1578759437
Provider Name (Legal Business Name): TIMOTHY C. MOORE, DDS, MSD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 PARCHMENT DR SE SUITE # 200
GRAND RAPIDS MI
49546-2374
US

IV. Provider business mailing address

826 PARCHMENT DR SE SUITE # 200
GRAND RAPIDS MI
49546-2374
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-9509
  • Fax: 616-285-8856
Mailing address:
  • Phone: 616-285-9509
  • Fax: 616-285-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901010163
License Number StateMI

VIII. Authorized Official

Name: DR. TIMOTHY CHARLES MOORE
Title or Position: PRESIDENT
Credential: DDS, MSD
Phone: 616-285-9509