Provider Demographics
NPI:1548641814
Name:MOAK, LORA B (DMD)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:B
Last Name:MOAK
Suffix:
Gender:F
Credentials:DMD
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 2080
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-2080
Mailing Address - Country:US
Mailing Address - Phone:606-794-4201
Mailing Address - Fax:304-235-8559
Practice Address - Street 1:180 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3602
Practice Address - Country:US
Practice Address - Phone:304-236-5902
Practice Address - Fax:304-235-8559
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21270122300000X
WV44131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015071800Medicaid