Healthcare Provider Details

I. General information

NPI: 1528162658
Provider Name (Legal Business Name): MARC TED JOHN MOYER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 WASHINGTON SQUARE SOUTH
PHILADELPHIA PA
19606
US

IV. Provider business mailing address

604 WASHINGTON SQUARE SOUTH
PHILIADELPHIA PA
19606
US

V. Phone/Fax

Practice location:
  • Phone: 215-627-0777
  • Fax: 215-627-0778
Mailing address:
  • Phone: 215-990-8423
  • Fax: 215-627-0778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036773
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: