1518987254 NPI number — DR. JASON MICHAEL MOORE D.M.D.

Table of content: DR. JASON MICHAEL MOORE D.M.D. (NPI 1518987254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518987254 NPI number — DR. JASON MICHAEL MOORE D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JASON
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518987254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19320 SEACOVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33558-9745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-949-7409
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8963 RACE TRACK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33635-9724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-818-8054
Provider Business Practice Location Address Fax Number:
813-818-9683
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN16030 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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