Provider Demographics
NPI:1962766808
Name:POAGE, JOHN MOYER (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MOYER
Last Name:POAGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:MOYER
Other - Last Name:POAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4716 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1944
Mailing Address - Country:US
Mailing Address - Phone:763-572-9762
Mailing Address - Fax:763-572-2127
Practice Address - Street 1:4716 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-1944
Practice Address - Country:US
Practice Address - Phone:763-572-9762
Practice Address - Fax:763-572-2127
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist