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General NPI Number Information
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NPI Number | 1912811910
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Entity Type | Organization
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Legal Business Name | STAR DENTAL CANON CITY
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Dates
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Enumeration Date | 09/29/2026
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Last Update Date | 09/29/2026
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Provider Practice Location Address
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Address Line | 410 MACON AVE
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City | CANON CITY
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State | CO
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Zip | 81212-3225
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Country | US
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Telephone | 719-276-0128
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Fax |
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Provider Business Mailing Address
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Address Line | 410 MACON AVE
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City | CANON CITY
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State | CO
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Zip | 81212-3225
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Country | US
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Telephone | 719-276-0128
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | GARY MOORE
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Credential | DDS
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Telephone | 719-640-6407
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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 |
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License Number State | NULL
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Taxonomy #2
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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 | NULL
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