Provider Demographics
NPI:1811089881
Name:MOORE, MICHAEL JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
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 1:6668 CHICK EVANS LANE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517
Mailing Address - Country:US
Mailing Address - Phone:630-416-7743
Mailing Address - Fax:
Practice Address - Street 1:4745 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532
Practice Address - Country:US
Practice Address - Phone:630-968-5078
Practice Address - Fax:630-968-3621
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice