Healthcare Provider Details

I. General information

NPI: 1730676990
Provider Name (Legal Business Name): ALEX MOORE, DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 BRYNWOOD DR STE 205
ROCKFORD IL
61114
US

IV. Provider business mailing address

6050 BRYNWOOD DR STE 205
ROCKFORD IL
61114-6579
US

V. Phone/Fax

Practice location:
  • Phone: 815-201-5955
  • Fax: 815-201-5956
Mailing address:
  • Phone: 815-201-5955
  • Fax: 815-201-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEX MOORE
Title or Position: DENTIST
Credential:
Phone: 815-621-6060