Provider Demographics
NPI:1396847216
Name:MOORE, KELLY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JAMES
Last Name:MOORE
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 1:404 JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4626
Mailing Address - Country:US
Mailing Address - Phone:815-399-7757
Mailing Address - Fax:
Practice Address - Street 1:6075 VANTAGE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5905
Practice Address - Country:US
Practice Address - Phone:815-399-9040
Practice Address - Fax:815-399-9336
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice