Healthcare Provider Details

I. General information

NPI: 1659060432
Provider Name (Legal Business Name): GRACE A MOSLEY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2433 MALONEY DR
BLOOMINGTON IL
61704-3750
US

IV. Provider business mailing address

1037 WHITE PINE RD
NORMAL IL
61761-6199
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-9042
  • Fax:
Mailing address:
  • Phone: 317-529-7687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: