Provider Demographics
NPI:1639503519
Name:MOORE, KRISTIN NICOLE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W IL ROUTE 22
Mailing Address - Street 2:SUITE 170
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3416
Mailing Address - Country:US
Mailing Address - Phone:847-438-9090
Mailing Address - Fax:
Practice Address - Street 1:900 W IL ROUTE 22
Practice Address - Street 2:SUITE 170
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3416
Practice Address - Country:US
Practice Address - Phone:847-438-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028048122300000X
IL0210024741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist