Basic Information
Provider Information | |||||||||
NPI: | 1003343708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE YOUNAN | ||||||||
FirstName: | ARLENE | ||||||||
MiddleName: | TEANA ZAKIA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORE YOUNAN | ||||||||
OtherFirstName: | KIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 670 9TH ST STE 203 | ||||||||
Address2: |   | ||||||||
City: | ARCATA | ||||||||
State: | CA | ||||||||
PostalCode: | 955216249 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078268633 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3750 ROHNERVILLE ROAD | ||||||||
Address2: |   | ||||||||
City: | FORTUNA | ||||||||
State: | CA | ||||||||
PostalCode: | 95540 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7076172555 | ||||||||
FaxNumber: | 7077257843 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2017 | ||||||||
LastUpdateDate: | 10/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 1223D0001X | 104884 | CA | Y |   | Dental Providers | Dentist | Dental Public Health |
No ID Information.