Healthcare Provider Details

I. General information

NPI: 1063359917
Provider Name (Legal Business Name): NICHOLAS MOORE DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 W 32ND ST STE HIJ
JOPLIN MO
64804-1606
US

IV. Provider business mailing address

1802 W 32ND ST STE HIJ
JOPLIN MO
64804-1606
US

V. Phone/Fax

Practice location:
  • Phone: 816-699-0732
  • Fax:
Mailing address:
  • Phone: 816-699-0732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS JAY MOORE
Title or Position: OWNER DENTIST
Credential: D.D.S.
Phone: 816-699-0732