Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 19A14367 | IL |
NPI | 1013026624 |
---|---|
Provider Name | Dr. Thomas Ryan Moss |
First Address | Rockford, IL 61104 |
Second Address | Rockford, IL 61104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2006 |
Last Update Date | 08/07/2007 |