Healthcare Provider Details

I. General information

NPI: 1033228887
Provider Name (Legal Business Name): NATHAN SETH MOORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2313 SANTA CLARA J1
SANTA CLARA UT
84765-5472
US

IV. Provider business mailing address

2313 SANTA CLARA J1
SANTA CLARA UT
84765-5472
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-4100
  • Fax: 435-673-3978
Mailing address:
  • Phone: 435-652-4100
  • Fax: 435-673-3978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number51080169922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: