Individual
DR. SHANNON KENNETH MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD MSED
Contact information
Practice address
2815 N WALNUT STREET, BLOOMINGTON, IN 47404-2077
(812) 332-1405
(812) 332-4331
Mailing address
2815 N WALNUT STREET, BLOOMINGTON, IN 47404-2077
(812) 332-1405
(812) 332-4331
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12010311A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200326230
—
IN
Enumeration date
03/07/2007
Last updated
03/16/2022
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