Provider Demographics
NPI:1154481075
Name:MOON, WILLIAM A (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:MOON
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 1:1290 GOLFVIEW AVE
Mailing Address - Street 2:ATTN: ACCOUNTS RECEIVABLE
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6740
Mailing Address - Country:US
Mailing Address - Phone:863-519-7900
Mailing Address - Fax:863-519-7696
Practice Address - Street 1:1700 BAKER AVE EAST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4325
Practice Address - Country:US
Practice Address - Phone:863-419-3252
Practice Address - Fax:863-419-3497
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN74691223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN7469OtherLICENSE