MEDICARE: THERESA MOORE RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH000201990	CO

General Provider Information

NPI Number	:	1104224104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MOORE RDH

Provider Business Mailing Address
First Line	:	1250 S PARKER RD STE 102
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-2178
Country	:	US
Telephone Number	:	303-755-6341
Fax Number	:	303-873-9886

Provider Business Practice Location Address
First Line	:	1250 S PARKER RD STE 102
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-2178
Country	:	US
Telephone Number	:	303-755-6341
Fax Number	:	303-873-9886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	12/08/2014

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