Provider Demographics
NPI:1720158470
Name:MOORE, BRENT ALLEN (DDS)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ALLEN
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 1:14575 LANSING PLACE
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038
Mailing Address - Country:US
Mailing Address - Phone:317-679-8207
Mailing Address - Fax:866-511-4151
Practice Address - Street 1:11630 OLIO RD
Practice Address - Street 2:SUITE #100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7677
Practice Address - Country:US
Practice Address - Phone:317-348-1354
Practice Address - Fax:866-511-4151
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010751A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice