1184013575 NPI number — KRISTIN N. MOORE, D.M.D., M.S., P.C.

Table of content: (NPI 1184013575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184013575 NPI number — KRISTIN N. MOORE, D.M.D., M.S., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRISTIN N. MOORE, D.M.D., M.S., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184013575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 WEST ROUTE 22
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
LAKE ZURICH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-438-9090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 WEST IL ROUTE 22
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
LAKE ZURICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-438-9090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/OWNER
Authorized Official Telephone Number:
847-401-3283

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  021.002474 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1639503519 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".