Healthcare Provider Details

I. General information

NPI: 1578775557
Provider Name (Legal Business Name): RANDALL DAVID MOY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 LEE ST SUITE A
DES PLAINES IL
60016-4646
US

IV. Provider business mailing address

490 LEE ST SUITE A
DES PLAINES IL
60016-4646
US

V. Phone/Fax

Practice location:
  • Phone: 847-699-8655
  • Fax: 847-699-8660
Mailing address:
  • Phone: 847-699-8655
  • Fax: 847-699-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: