Basic Information
| Provider Information | |||||||||
| NPI: | 1700129400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOOREFIELD | ||||||||
| FirstName: | KALLIE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 290 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709169000 | ||||||||
| FaxNumber: | 6782477862 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 RED CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401413750 | VA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 10183 | SC | Y | Dental Providers | Dentist | General Practice |
No ID Information.