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General NPI Number Information
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NPI Number | 1023678992
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Entity Type | Individual
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Provider Name | MICHAEL MORAN DMD
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Gender | Male
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Dates
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Enumeration Date | 06/13/2019
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Last Update Date | 06/13/2019
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Provider Practice Location Address
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Address Line | 1508 W 10TH ST
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City | LAUREL
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State | MS
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Zip | 39440-2668
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Country | US
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Telephone | 601-428-6093
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Fax |
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Provider Business Mailing Address
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Address Line | 106 MELISSA LN
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City | HATTIESBURG
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State | MS
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Zip | 39402-3330
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Country | US
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Telephone | 601-319-5717
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4059-19
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License Number State | MS
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