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General NPI Number Information
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NPI Number | 1376656819
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Entity Type | Individual
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Provider Name | CHARLES WALTER MOORE D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1319 CAULKS HILL RD
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City | SAINT CHARLES
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State | MO
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Zip | 63304-6863
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Country | US
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Telephone | 636-441-3430
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Fax |
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Provider Business Mailing Address
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Address Line | 601 HIDDEN LAKE DR
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City | SAINT PETERS
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State | MO
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Zip | 63376-3307
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Country | US
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Telephone | 636-928-3302
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 013916
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License Number State | MO
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