MEDICARE: DR. STACY DAVIS MOORMAN 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	1223G0001X	General Practice Dentistry	OH02350	OH
2	122300000X	Dentist	30.020350	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	803310	OTHER	OH	UNITED CONCORDIA PROVIDER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295735892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY DAVIS MOORMAN DDS

Provider Business Mailing Address
First Line	:	14062 US HIGHWAY 23
Second Line	:	SUITE B
City	:	WAVERLY
State	:	OH
Zip	:	45690-9415
Country	:	US
Telephone Number	:	740-947-1990
Fax Number	:

Provider Business Practice Location Address
First Line	:	14062 US HIGHWAY 23
Second Line	:	SUITE B
City	:	WAVERLY
State	:	OH
Zip	:	45690-9415
Country	:	US
Telephone Number	:	740-947-1990
Fax Number	:

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	04/20/2023

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