Provider Demographics
NPI:1215664271
Name:MOORE, KRYSTAL HEATON (DDS)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:HEATON
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 STATE HIGHWAY 121 APT 302
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4062
Mailing Address - Country:US
Mailing Address - Phone:817-874-7430
Mailing Address - Fax:
Practice Address - Street 1:1818 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1391
Practice Address - Country:US
Practice Address - Phone:817-874-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38753122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist