Provider Demographics
NPI:1164548806
Name:MOON, SUE K (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:K
Last Name:MOON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CARDINAL PARK DR SE
Mailing Address - Street 2:SUITE 206-A
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4448
Mailing Address - Country:US
Mailing Address - Phone:703-771-1515
Mailing Address - Fax:703-771-8242
Practice Address - Street 1:2 CARDINAL PARK DR SE
Practice Address - Street 2:SUITE 206-A
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-4448
Practice Address - Country:US
Practice Address - Phone:703-771-1515
Practice Address - Fax:703-771-8242
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014103851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice