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General NPI Number Information
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NPI Number | 1265588420
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Entity Type | Organization
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Legal Business Name | THEODORE L MOSS DMD MS PC
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Dates
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Enumeration Date | 01/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 804 FREEPORT RD
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City | STERLING
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State | IL
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Zip | 61081-3028
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Country | US
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Telephone | 815-625-3504
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Fax |
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Provider Business Mailing Address
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Address Line | 677 FOREST HILL RD
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City | LAKE FOREST
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State | IL
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Zip | 60045-3127
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Country | US
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Telephone | 847-295-7581
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THEODORE LEE MOSS
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Credential | DMD
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Telephone | 847-295-7581
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 1915769
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License Number State | IL
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