Provider Demographics
NPI:1043385701
Name:MOON, WILLIAM H JR (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:MOON
Suffix:JR
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 1:2547 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433
Mailing Address - Country:US
Mailing Address - Phone:810-733-0396
Mailing Address - Fax:
Practice Address - Street 1:1481 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509
Practice Address - Country:US
Practice Address - Phone:810-744-2982
Practice Address - Fax:810-744-2983
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
J116030Medicare UPIN