Provider Demographics
NPI:1235747171
Name:MOORE, GRACE ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 MILLRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1117
Mailing Address - Country:US
Mailing Address - Phone:317-371-0555
Mailing Address - Fax:
Practice Address - Street 1:1610 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2659
Practice Address - Country:US
Practice Address - Phone:630-423-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0327631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice