Healthcare Provider Details

I. General information

NPI: 1750375317
Provider Name (Legal Business Name): RICHARD J MORI DMD LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 LINDEN AVE
DAYTON OH
45432-3031
US

IV. Provider business mailing address

1580 SCOTTSGATE CT N
XENIA OH
45385-8514
US

V. Phone/Fax

Practice location:
  • Phone: 937-252-9564
  • Fax: 937-254-5071
Mailing address:
  • Phone: 937-320-1504
  • Fax: 937-254-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30-02-1065
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: