Provider Demographics
NPI:1083159438
Name:WILLIAM H MOON JR DDS
Entity Type:Organization
Organization Name:WILLIAM H MOON JR DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-744-2982
Mailing Address - Street 1:1481 SOUTH CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1481 SOUTH CENTER ROAD
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J116030Medicare UPIN