Provider Demographics
NPI:1366598526
Name:MOSS, THEODORE LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:LEE
Last Name:MOSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-3127
Mailing Address - Country:US
Mailing Address - Phone:847-295-7581
Mailing Address - Fax:847-295-7582
Practice Address - Street 1:804 FREEPORT RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-3028
Practice Address - Country:US
Practice Address - Phone:815-625-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19157691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003057Medicaid