Healthcare Provider Details

I. General information

NPI: 1033678412
Provider Name (Legal Business Name): MICHAEL J MOORE RDH, LAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 AGENCY MAIN ST
HARLEM MT
59526-9455
US

IV. Provider business mailing address

1112 6TH ST
HAVRE MT
59501-4119
US

V. Phone/Fax

Practice location:
  • Phone: 406-353-3168
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11523
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: