Provider Demographics
NPI:1588787782
Name:AVERY-MOORE, KRYSTE
Entity type:Individual
Prefix:DR
First Name:KRYSTE
Middle Name:
Last Name:AVERY-MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WILLIAM ST
Mailing Address - Street 2:ROOM 111
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1304
Mailing Address - Country:US
Mailing Address - Phone:973-733-7590
Mailing Address - Fax:
Practice Address - Street 1:110 WILLIAM ST
Practice Address - Street 2:ROOM 111
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1304
Practice Address - Country:US
Practice Address - Phone:973-733-7590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI101843100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist