Provider Demographics
NPI:1881600146
Name:MOORE, JAMES GRAY (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GRAY
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:PO BOX 24736
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-4736
Mailing Address - Country:US
Mailing Address - Phone:803-865-0645
Mailing Address - Fax:803-865-5015
Practice Address - Street 1:700 RABON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8900
Practice Address - Country:US
Practice Address - Phone:803-865-0645
Practice Address - Fax:803-865-5015
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2749Medicaid