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General NPI Number Information
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NPI Number | 1649952086
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Entity Type | Organization
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Legal Business Name | MOORE LEGACY DENTAL
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Dates
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Enumeration Date | 08/04/2023
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Last Update Date | 08/04/2023
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Provider Practice Location Address
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Address Line | 4896 S 1900 W STE B
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City | ROY
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State | UT
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Zip | 84067-2994
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Country | US
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Telephone | 801-773-9198
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Fax | 208-444-9804
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Provider Business Mailing Address
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Address Line | 4896 S 1900 W STE B
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City | ROY
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State | UT
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Zip | 84067-2994
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Country | US
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Telephone | 801-773-9198
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Fax | 208-444-9804
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Authorized Official
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Title or Position | OWNER
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Name | MRS. ELISE NICOLE VAN TASSELL
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Credential |
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Telephone | 385-239-0028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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