Provider Demographics
NPI:1487213583
Name:MOON, AUSTIN LEE (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LEE
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 1:770 PINEY FOREST RD STE A
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2876
Mailing Address - Country:US
Mailing Address - Phone:434-799-8825
Mailing Address - Fax:
Practice Address - Street 1:770 PINEY FOREST RD STE A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2876
Practice Address - Country:US
Practice Address - Phone:434-799-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014165201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice