Provider Demographics
NPI:1669468344
Name:MOORE, REX DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:DALE
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 1:2103 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4310
Mailing Address - Country:US
Mailing Address - Phone:309-662-3123
Mailing Address - Fax:309-661-0798
Practice Address - Street 1:2103 E WASHINGTON ST
Practice Address - Street 2:STE 3E
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4310
Practice Address - Country:US
Practice Address - Phone:309-662-3123
Practice Address - Fax:309-661-0798
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice