MEDICARE: JACOB MOORHEAD DMD

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	D011356	AZ

General Provider Information

NPI Number	:	1922746858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MOORHEAD DMD

Provider Business Mailing Address
First Line	:	1130 S COUNTRY CLUB DR STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-4639
Country	:	US
Telephone Number	:	480-461-9866
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 S COUNTRY CLUB DR STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-4639
Country	:	US
Telephone Number	:	480-461-9866
Fax Number	:

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

Provider Enumeration Date	:	05/20/2022
Last Update Date	:	05/17/2023

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