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General NPI Number Information
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NPI Number | 1639202914
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Entity Type | Organization
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Legal Business Name | THOMAS H. MOORE DDS LTD
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6075 VANTAGE PL
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City | ROCKFORD
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State | IL
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Zip | 61107-5905
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Country | US
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Telephone | 815-399-0677
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Fax |
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Provider Business Mailing Address
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Address Line | 4298 WINDSWEPT WAY
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City | LOVES PARK
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State | IL
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Zip | 61111-8654
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Country | US
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Telephone | 815-636-6673
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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. RYAN THOMAS MOORE
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Credential | D.D.S.
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Telephone | 815-399-0677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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