Healthcare Provider Details

I. General information

NPI: 1447318803
Provider Name (Legal Business Name): JEFFREY MORGAN MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11765 MCMINNVILLE HWY
WALLING TN
38587
US

IV. Provider business mailing address

11765 MCMINNVILLE HWY
WALLING TN
38587-5040
US

V. Phone/Fax

Practice location:
  • Phone: 931-657-5204
  • Fax: 931-657-2134
Mailing address:
  • Phone: 931-657-5204
  • Fax: 931-657-2134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS 4172
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: