MEDICARE: BRAZILE AND MOOREHEAD PLLC

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

General Provider Information

NPI Number	:	1760134746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZILE AND MOOREHEAD PLLC

Provider Business Mailing Address
First Line	:	763 PROSPECT LN
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8164
Country	:	US
Telephone Number	:
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	:	704-968-6558
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TATYANIA MOOREHEAD
Credential	:	DDS
Telephone Number	:	704-968-6558

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	01/21/2022

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