Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 7570 | NE |
NPI | 1003478611 |
---|---|
Provider Name | Dr. Grace Moore |
First Address | Lincoln, NE 68504-2218 |
Second Address | Lincoln, NE 68583-1530 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2019 |
Last Update Date | 03/07/2019 |