Healthcare Provider Details

I. General information

NPI: 1205833159
Provider Name (Legal Business Name): JEFFERY ORLAND MOYER D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 BROADWAY ST
LAMAR MO
64759-1224
US

IV. Provider business mailing address

805 BROADWAY ST
LAMAR MO
64759-1224
US

V. Phone/Fax

Practice location:
  • Phone: 417-682-5871
  • Fax: 417-682-6791
Mailing address:
  • Phone: 417-682-5871
  • Fax: 417-682-6791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13806
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: