Healthcare Provider Details

I. General information

NPI: 1487701942
Provider Name (Legal Business Name): RICHARD WALLACE MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 SW GREENBURG ROAD SUITE 150
TIGARD OR
97223-5529
US

IV. Provider business mailing address

10220 SW GREENBURG ROAD SUITE 150
TIGARD OR
97223-5529
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-1200
  • Fax: 503-408-6856
Mailing address:
  • Phone: 503-255-1200
  • Fax: 503-408-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5689
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: