Provider Demographics
NPI:1013026624
Name:MOSS, THOMAS RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RYAN
Last Name:MOSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104
Mailing Address - Country:US
Mailing Address - Phone:815-964-5121
Mailing Address - Fax:815-964-6105
Practice Address - Street 1:1415 E STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:815-964-5121
Practice Address - Fax:815-964-6105
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A14367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist