Healthcare Provider Details

I. General information

NPI: 1467563262
Provider Name (Legal Business Name): MARLON K MOORE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 EASTCHESTER RD STE 230
BRONX NY
10461-2335
US

IV. Provider business mailing address

1776 EASTCHESTER RD STE 230
BRONX NY
10461-2335
US

V. Phone/Fax

Practice location:
  • Phone: 718-518-1776
  • Fax: 718-918-1776
Mailing address:
  • Phone: 718-518-1776
  • Fax: 718-918-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number045968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: