Healthcare Provider Details

I. General information

NPI: 1619087558
Provider Name (Legal Business Name): ERNEST HOUSTON MOORE D.D. S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 N 3RD ST
MABANK TX
75147-8611
US

IV. Provider business mailing address

9545 FM 1836
KAUFMAN TX
75142-6930
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-4405
  • Fax:
Mailing address:
  • Phone: 972-962-6388
  • Fax: 214-368-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8211
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: