Provider Demographics
NPI:1922618594
Name:MOORE, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:FORD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3818
Mailing Address - Country:US
Mailing Address - Phone:312-572-4785
Mailing Address - Fax:
Practice Address - Street 1:2020 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3741
Practice Address - Country:US
Practice Address - Phone:312-572-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.011098124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist