=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558814897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS H. MOORE D.D.S. LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2016
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6075 VANTAGE PL
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-399-0677
-----------------------------------------------------
Fax | 815-986-1352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6075 VANTAGE PL
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-399-0677
-----------------------------------------------------
Fax | 815-986-1352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. RYAN MOORE
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 815-399-0677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.030757
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------