Basic Information
| Provider Information | |||||||||
| NPI: | 1629171160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORMAN | ||||||||
| FirstName: | BRIGHAM | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1719 BARNESDALE WAY NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303092601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048790176 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709165028 | ||||||||
| FaxNumber: | 6783027485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 37456 | CA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DN01856 | GA | Y | Dental Providers | Dentist | General Practice | 1223G0001X | 048628-1 | NY | N | Dental Providers | Dentist | General Practice | 1223G0001X | 0401411240 | VA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 21505 | MA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 12010805A | IN | N | Dental Providers | Dentist | General Practice | 1223G0001X | 7025 | AZ | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 9180712 | 05 | VA | MEDICAID | 0205516 | 05 | MA | MEDICAID |