Provider Demographics
NPI:1316529332
Name:MOORE, DILLON RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:DILLON
Middle Name:RAYMOND
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 1:39 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4003
Mailing Address - Country:US
Mailing Address - Phone:401-722-0081
Mailing Address - Fax:
Practice Address - Street 1:39 EAST AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4003
Practice Address - Country:US
Practice Address - Phone:401-722-0081
Practice Address - Fax:401-312-0318
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN035981223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDEN03598OtherRI STATE LICENSE