Provider Demographics
NPI:1366575722
Name:MOORE, TOM HAROLD (DDS)
Entity type:Individual
Prefix:DR
First Name:TOM
Middle Name:HAROLD
Last Name:MOORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4318 OWEN CENTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-6108
Mailing Address - Country:US
Mailing Address - Phone:815-963-8368
Mailing Address - Fax:
Practice Address - Street 1:6075 VANTAGE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5905
Practice Address - Country:US
Practice Address - Phone:815-399-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A134101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003035Medicare ID - Type Unspecified