MEDICARE: TATYANIA MOOREHEAD

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	9963	SC
2	122300000X	Dentist	11717	NC
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1659831618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATYANIA MOOREHEAD

Provider Business Mailing Address
First Line	:	8700 PINEVILLE MATTHEWS RD STE 920
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4748
Country	:	US
Telephone Number	:	704-336-9595
Fax Number	:

Provider Business Practice Location Address
First Line	:	8700 PINEVILLE MATTHEWS RD STE 920
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4748
Country	:	US
Telephone Number	:	704-336-9595
Fax Number	:

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

Provider Enumeration Date	:	03/24/2019
Last Update Date	:	03/14/2026

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