Provider Demographics
NPI:1386869287
Name:MORAN, DANIEL T (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:T
Last Name:MORAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 W CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60112-4107
Mailing Address - Country:US
Mailing Address - Phone:815-787-8408
Mailing Address - Fax:
Practice Address - Street 1:4105 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1115
Practice Address - Country:US
Practice Address - Phone:815-223-5839
Practice Address - Fax:815-223-0957
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice