MEDICARE: KRYSTAL HEATON MOORE DDS

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	122300000X	Dentist	38753	TX
2	1223G0001X	General Practice Dentistry	38753	TX

General Provider Information

NPI Number	:	1215664271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL HEATON MOORE DDS

Provider Business Mailing Address
First Line	:	2400 STATE HIGHWAY 121 APT 302
Second Line	:
City	:	EULESS
State	:	TX
Zip	:	76039-4062
Country	:	US
Telephone Number	:	817-874-7430
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1391
Country	:	US
Telephone Number	:	817-874-7430
Fax Number	:

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

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2022

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