=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568145795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE FAMILY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2023
-----------------------------------------------------
Last Update Date | 08/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 S TELEPHONE RD
-----------------------------------------------------
City | MOORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73160-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-206-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 SE 89TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73135-6017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-206-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LOREN P ISRAELSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 361-405-9080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------