Provider Demographics
NPI:1124557228
Name:MOORE, ALEX (DMD, MS)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 BRYNWOOD DR STE 205
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6579
Mailing Address - Country:US
Mailing Address - Phone:815-621-6060
Mailing Address - Fax:
Practice Address - Street 1:6050 BRYNWOOD DR STE 205
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6579
Practice Address - Country:US
Practice Address - Phone:816-201-5955
Practice Address - Fax:815-201-5956
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001449-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist