Provider Demographics
NPI:1386932143
Name:MOORE, RYAN (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:811 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5923
Mailing Address - Country:US
Mailing Address - Phone:870-246-2221
Mailing Address - Fax:870-246-5923
Practice Address - Street 1:811 CLINTON ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5923
Practice Address - Country:US
Practice Address - Phone:870-246-2221
Practice Address - Fax:870-246-2532
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR21305563Medicaid
AR188398608Medicaid