Provider Demographics
NPI:1477759546
Name:MOON, YOUNG JIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:JIN
Last Name:MOON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LENTZ DR
Mailing Address - Street 2:SUITE 60
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-5135
Mailing Address - Country:US
Mailing Address - Phone:615-612-1740
Mailing Address - Fax:615-612-1751
Practice Address - Street 1:500 LENTZ DR
Practice Address - Street 2:SUITE 60
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-5135
Practice Address - Country:US
Practice Address - Phone:615-612-1740
Practice Address - Fax:615-612-1751
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN87051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018593Medicaid