Provider Demographics
NPI:1174864169
Name:SUR, JI MOON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JI MOON
Middle Name:
Last Name:SUR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6086 HILLBROOK PL
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-7316
Mailing Address - Country:US
Mailing Address - Phone:215-275-4585
Mailing Address - Fax:
Practice Address - Street 1:5073 PIPER GLEN TER
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-7490
Practice Address - Country:US
Practice Address - Phone:215-275-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1053291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice