Provider Demographics
NPI:1275543506
Name:MOYNIHAN, CAROL BALAN (DDS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:BALAN
Last Name:MOYNIHAN
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 1:14403 BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5348
Mailing Address - Country:US
Mailing Address - Phone:734-864-8729
Mailing Address - Fax:
Practice Address - Street 1:35 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3287
Practice Address - Country:US
Practice Address - Phone:734-697-3011
Practice Address - Fax:734-697-3779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice