Healthcare Provider Details

I. General information

NPI: 1003478611
Provider Name (Legal Business Name): GRACE MOORE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CAMPUS LOOP S
LINCOLN NE
68583-1530
US

IV. Provider business mailing address

5402 GREENWOOD ST
LINCOLN NE
68504-2218
US

V. Phone/Fax

Practice location:
  • Phone: 402-472-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7570
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: