Provider Demographics
NPI:1285853242
Name:MOEN, ROBERT CARL (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CARL
Last Name:MOEN
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 1:948 S CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5347
Mailing Address - Country:US
Mailing Address - Phone:630-279-4781
Mailing Address - Fax:
Practice Address - Street 1:2 W TALCOTT RD
Practice Address - Street 2:SUITE 15
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5556
Practice Address - Country:US
Practice Address - Phone:847-825-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice