Healthcare Provider Details

I. General information

NPI: 1295040699
Provider Name (Legal Business Name): VERCELL MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 HICKS ST
BROOKLYN NY
11201-5509
US

IV. Provider business mailing address

5800 3RD AVE
BROOKLYN NY
11220-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-1243
  • Fax:
Mailing address:
  • Phone: 718-780-1243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020159
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: