Provider Demographics
NPI:1043615669
Name:DR. L.J. MOORE DDS PC
Entity Type:Organization
Organization Name:DR. L.J. MOORE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-779-8900
Mailing Address - Street 1:2407 W 104TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1006
Mailing Address - Country:US
Mailing Address - Phone:773-779-8900
Mailing Address - Fax:773-779-2085
Practice Address - Street 1:2407 W 104TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1006
Practice Address - Country:US
Practice Address - Phone:773-779-8900
Practice Address - Fax:773-779-2085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190149381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty