Individual
KELLIE LYNN MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
019031614
IL
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
019031614
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/28/2018
Last updated
06/22/2021
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