Provider Demographics
NPI:1417105313
Name:MOON FAMILY DENTISTRY, PA
Entity Type:Organization
Organization Name:MOON FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-414-6159
Mailing Address - Street 1:3718 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2912
Mailing Address - Country:US
Mailing Address - Phone:281-414-6159
Mailing Address - Fax:
Practice Address - Street 1:2803 BUSINESS CENTER DRIVE
Practice Address - Street 2:#121
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584
Practice Address - Country:US
Practice Address - Phone:713-436-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty