Provider Demographics
NPI:1588994123
Name:DC MORA DDS
Entity type:Organization
Organization Name:DC MORA DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-391-8882
Mailing Address - Street 1:1464 S CIRCLE ST
Mailing Address - Street 2:
Mailing Address - City:SEALY
Mailing Address - State:TX
Mailing Address - Zip Code:77474-3914
Mailing Address - Country:US
Mailing Address - Phone:979-627-7779
Mailing Address - Fax:979-627-7203
Practice Address - Street 1:1464 S CIRCLE ST
Practice Address - Street 2:
Practice Address - City:SEALY
Practice Address - State:TX
Practice Address - Zip Code:77474-3914
Practice Address - Country:US
Practice Address - Phone:979-627-7779
Practice Address - Fax:979-627-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801842281Medicaid