Healthcare Provider Details

I. General information

NPI: 1174708010
Provider Name (Legal Business Name): FREDERICK THOMAS MOORE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 ASHLEY AVE BSB 249,
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

173 ASHLEY AVE BSB 249, PO BOX 250507
CHARLESTON SC
29425-8908
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-0693
  • Fax: 843-792-1280
Mailing address:
  • Phone: 843-792-0693
  • Fax: 843-792-1280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: