Provider Demographics
NPI:1417970120
Name:MOSES, ALLEN JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:JACK
Last Name:MOSES
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 1:233 S WACKER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-6306
Mailing Address - Country:US
Mailing Address - Phone:312-993-0430
Mailing Address - Fax:312-993-9140
Practice Address - Street 1:233 S WACKER DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-6306
Practice Address - Country:US
Practice Address - Phone:312-993-0430
Practice Address - Fax:312-993-9140
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice