Provider Demographics
NPI:1548890452
Name:MOORE, LAURA ELISABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELISABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 E WOODSIDE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-4206
Mailing Address - Country:US
Mailing Address - Phone:417-268-8662
Mailing Address - Fax:
Practice Address - Street 1:1524 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6565
Practice Address - Country:US
Practice Address - Phone:417-888-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190407451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics