Healthcare Provider Details

I. General information

NPI: 1225695703
Provider Name (Legal Business Name): NICHOLAS JAY MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 08/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W 32ND STREET
JOPLIN MO
64804
US

IV. Provider business mailing address

401 HERITAGE ACRES DRIVE
JOPLIN MO
64801
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-5600
  • Fax: 417-868-8263
Mailing address:
  • Phone: 816-699-0732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2019016638
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: