Provider Demographics
NPI:1265588420
Name:THEODORE L MOSS DMD MS PC
Entity type:Organization
Organization Name:THEODORE L MOSS DMD MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-295-7581
Mailing Address - Street 1:677 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-3127
Mailing Address - Country:US
Mailing Address - Phone:847-295-7581
Mailing Address - Fax:
Practice Address - Street 1:804 FREEPORT RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-3028
Practice Address - Country:US
Practice Address - Phone:815-625-3504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19157691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003057Medicaid