Healthcare Provider Details

I. General information

NPI: 1639238264
Provider Name (Legal Business Name): PAUL T MOORE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 SOUTH SHADY AVE.
DAMASCUS VA
24236
US

IV. Provider business mailing address

306 SOUTH SHADY AVE.
DAMASCUS VA
24236
US

V. Phone/Fax

Practice location:
  • Phone: 276-475-5116
  • Fax: 276-475-5665
Mailing address:
  • Phone: 276-475-5116
  • Fax: 276-475-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008807
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: