Basic Information
| Provider Information | |||||||||
| NPI: | 1376605196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | WALKER | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D. D. S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 RIDGE AVE SW | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4687 ROCKBRIDGE RD | ||||||||
| Address2: | SUITE #7 | ||||||||
| City: | STONE MOUNTAIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300834258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042969070 | ||||||||
| FaxNumber: | 4042963456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | GA 7613 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | GA 7613 | 05 | GA | MEDICAID |