MEDICARE: BRIGHAM R 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	37456	CA
2	1223G0001X	General Practice Dentistry	DN01856	GA
3	1223G0001X	General Practice Dentistry	048628-1	NY
4	1223G0001X	General Practice Dentistry	0401411240	VA
5	1223G0001X	General Practice Dentistry	21505	MA
6	1223G0001X	General Practice Dentistry	12010805A	IN
7	1223G0001X	General Practice Dentistry	7025	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629171160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIGHAM R MOORMAN DDS

Provider Business Mailing Address
First Line	:	1719 BARNESDALE WAY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-2601
Country	:	US
Telephone Number	:	404-879-0176
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 GALLERIA PKWY SE
Second Line	:	SUITE 800
City	:	ATLANTA
State	:	GA
Zip	:	30339-5980
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:	678-302-7485

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

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	07/08/2007

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Directions to “ BRIGHAM R MOORMAN DDS” Practice Location

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