Provider Demographics
NPI:1487701942
Name:MOORE, RICHARD WALLACE (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WALLACE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 SW GREENBURG ROAD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5529
Mailing Address - Country:US
Mailing Address - Phone:503-255-1200
Mailing Address - Fax:503-408-6856
Practice Address - Street 1:10220 SW GREENBURG ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5529
Practice Address - Country:US
Practice Address - Phone:503-255-1200
Practice Address - Fax:503-408-6856
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist