Provider Demographics
NPI:1710788591
Name:LAKE PLAZA MOORE-AMS, PLLC
Entity type:Organization
Organization Name:LAKE PLAZA MOORE-AMS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARHILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:540-680-0923
Mailing Address - Street 1:36101 GOODWIN DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-2029
Mailing Address - Country:US
Mailing Address - Phone:540-972-8100
Mailing Address - Fax:540-972-8300
Practice Address - Street 1:36101 GOODWIN DR
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-2029
Practice Address - Country:US
Practice Address - Phone:540-972-8100
Practice Address - Fax:540-972-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental