Basic Information
Provider Information | |||||||||
NPI: | 1154805117 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ANDREA MOORE DENTAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE DENTAL OFFICE OF BEAUMONT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 920050 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753920050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458890 | ||||||||
FaxNumber: | 3029520892 | ||||||||
Practice Location | |||||||||
Address1: | 1620 E 1ST ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | BEAUMONT | ||||||||
State: | CA | ||||||||
PostalCode: | 922233174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9518008095 | ||||||||
FaxNumber: | 9518008095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2018 | ||||||||
LastUpdateDate: | 08/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | ANDREA | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
AuthorizedOfficialTelephone: | 9518008095 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 08/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.