Provider Demographics
NPI:1376522979
Name:MOORE, GARY N (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:N
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 1:3695 STAR RANCH RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-5980
Mailing Address - Country:US
Mailing Address - Phone:719-597-7979
Mailing Address - Fax:719-597-8084
Practice Address - Street 1:3695 STAR RANCH RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-5980
Practice Address - Country:US
Practice Address - Phone:719-597-7979
Practice Address - Fax:719-597-8084
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89301223E0200X
NV32161223G0001X
CO85851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13954318Medicaid
CO1013331560Medicaid
CO1881255107OtherRM PACE