Provider Demographics
NPI:1225681000
Name:MOON, JI MIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JI MIN
Middle Name:
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 1:25519 CARROL CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3700
Mailing Address - Country:US
Mailing Address - Phone:951-215-5918
Mailing Address - Fax:
Practice Address - Street 1:919 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2407
Practice Address - Country:US
Practice Address - Phone:760-255-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice