Provider Demographics
NPI:1558814897
Name:THOMAS H. MOORE D.D.S. LTD
Entity Type:Organization
Organization Name:THOMAS H. MOORE D.D.S. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-399-0677
Mailing Address - Street 1:6075 VANTAGE PL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5905
Mailing Address - Country:US
Mailing Address - Phone:815-399-0677
Mailing Address - Fax:815-986-1352
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:815-399-0677
Practice Address - Fax:815-986-1352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0307571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty