Shannon Kenneth Moore, DMD MSED

Primary specialty

DentistTaxonomy code 122300000X

License

12010311A Issued in IN

Practice address

2815 N Walnut Street
Bloomington, IN 47404-2077

Phone

(812) 332-1405

Fax

(812) 332-4331

NPI assigned

Mar 7, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Create-a-Smile, PC

  • Dentist
  • Bloomington, IN
  • NPI 1588995229
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173225600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1647388800000",
    "number": "1194855205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2815 N WALNUT STREET",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474042077",
            "telephone_number": "812-332-1405",
            "fax_number": "812-332-4331"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2815 N WALNUT STREET",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474042077",
            "telephone_number": "812-332-1405",
            "fax_number": "812-332-4331"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MOORE",
        "first_name": "SHANNON",
        "middle_name": "KENNETH",
        "name_prefix": "Dr.",
        "credential": "DMD MSED",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-03-07",
        "last_updated": "2022-03-16",
        "certification_date": "2022-03-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IN",
            "license": "12010311A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200326230",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kelsi Moore
• Kevin Nelson Moore, PMHNP-BC, APRN
• Kevin T. Moore, M.D.
• Noah Moore
• Scot B Moore, MD
• Stephen G Moore, M.D.
• Adrian Morales
• Danielle Renee Moretti, RBT
• Margot Morgan, M.S.
• Sarah Elizabeth Morgan

• Dentist in Bloomington, IN
• Providers in Bloomington, IN by specialty
• Dentist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.