Healthcare Provider Details

I. General information

NPI: 1548890452
Provider Name (Legal Business Name): LAURA ELISABETH MOORE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 E BRADFORD PKWY
SPRINGFIELD MO
65804-6565
US

IV. Provider business mailing address

3551 E WOODSIDE ST
SPRINGFIELD MO
65809-4206
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-3030
  • Fax:
Mailing address:
  • Phone: 417-268-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2019040745
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: