Active NPI
Blake Edwin Moore, DDS
- Pediatric Dentistry
- Folsom, CA
National Provider Identifier
1801883756
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 64252
- Practice address
- 2190 E Bidwell St
Folsom, CA 95630-6453 - Phone
- (916) 984-0304
- NPI assigned
- Oct 5, 2005
- Last updated
- Dec 25, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 64252 | CA | Primary |
Addresses
Primary practice location
2190 E Bidwell St
Folsom, CA 95630-6453
Mailing address
2190 E Bidwell St
Folsom, CA 95630-6453
Phone (916) 984-0304
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 64252 | CA | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| S.Y. Jang DDS Corporatiom | Pediatric Dentistry | Past | Accepting new patients |
| Tavallaei, D.M.D., Corporation | Pediatric Dentistry | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1128470400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1577232000000",
"number": "1801883756",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2190 E BIDWELL ST",
"city": "FOLSOM",
"state": "CA",
"postal_code": "956306453",
"telephone_number": "916-984-0304"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2190 E BIDWELL ST",
"city": "FOLSOM",
"state": "CA",
"postal_code": "956306453",
"telephone_number": "916-984-0304"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOORE",
"first_name": "BLAKE",
"middle_name": "EDWIN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-10-05",
"last_updated": "2019-12-25",
"certification_date": "2019-12-25",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "CA",
"license": "64252",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Folsom, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 25, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.