Healthcare Provider Details

I. General information

NPI: 1013154673
Provider Name (Legal Business Name): ALFRED P MOORE DENTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WYTHE CREEK RD
POQUOSON VA
23662-1911
US

IV. Provider business mailing address

235 WYTHE CREEK RD
POQUOSON VA
23662-1911
US

V. Phone/Fax

Practice location:
  • Phone: 757-868-8152
  • Fax: 757-868-4507
Mailing address:
  • Phone: 757-868-8152
  • Fax: 757-868-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401004269
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: