Organization
THEODORE L MOSS DMD MS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THEODORE LEE MOSS DMD (PRESIDENT)
(847) 295-7581
Entity
Organization
Contact information
Practice address
804 FREEPORT RD, STERLING, IL 61081-3028
(815) 625-3504
Mailing address
677 FOREST HILL RD, LAKE FOREST, IL 60045-3127
(847) 295-7581
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
1915769
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1003057
—
IL
Enumeration date
01/28/2007
Last updated
08/22/2020
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