Provider Demographics
NPI:1891897799
Name:KELLY J. MOORE D.D.S., P.C.
Entity Type:Organization
Organization Name:KELLY J. MOORE D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-399-9040
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:815-399-9040
Mailing Address - Fax:815-399-9336
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-0033411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty