Provider Demographics
NPI:1053452250
Name:MOORE, DENNIS (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 WALLACE WAY
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-8805
Mailing Address - Country:US
Mailing Address - Phone:509-203-1080
Mailing Address - Fax:509-203-1077
Practice Address - Street 1:1003 WALLACE WAY
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-8805
Practice Address - Country:US
Practice Address - Phone:509-203-1080
Practice Address - Fax:509-203-1077
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9907208000000X
NVNV 99072080A0000X
WAMD61499857208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053452250Medicaid
NV002018572Medicaid
NVGD434ZMedicare PIN