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General NPI Number Information
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NPI Number | 1043615669
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Entity Type | Organization
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Legal Business Name | DR. L.J. MOORE DDS PC
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Dates
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Enumeration Date | 10/24/2014
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Last Update Date | 10/24/2014
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Provider Practice Location Address
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Address Line | 2407 W 104TH ST
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City | CHICAGO
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State | IL
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Zip | 60655-1006
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Country | US
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Telephone | 773-779-8900
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Fax | 773-779-2085
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Provider Business Mailing Address
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Address Line | 2407 W 104TH ST
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City | CHICAGO
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State | IL
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Zip | 60655-1006
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Country | US
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Telephone | 773-779-8900
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Fax | 773-779-2085
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. LEE JOSEPH MOORE
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Credential | D.D.S
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Telephone | 773-779-8900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019014938
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License Number State | IL
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