Provider Demographics
NPI:1992923866
Name:MOE, TERRY L (DDS)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:MOE
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 1:118 BROADWAY N STE 708
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4948
Mailing Address - Country:US
Mailing Address - Phone:701-232-8314
Mailing Address - Fax:
Practice Address - Street 1:118 BROADWAY N STE 708
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4948
Practice Address - Country:US
Practice Address - Phone:701-232-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice