Basic Information
| Provider Information | |||||||||
| NPI: | 1053452250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026413212 | ||||||||
| FaxNumber: | 7024590320 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 N NELLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891105382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026413212 | ||||||||
| FaxNumber: | 7024590320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | NV 9907 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | 9907 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1053452250 | 05 | NV | MEDICAID | 002018572 | 05 | NV | MEDICAID |