Provider Demographics
NPI:1508956012
Name:MOON, PAUL RANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RANDALL
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 1:2060 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2373
Mailing Address - Country:US
Mailing Address - Phone:530-527-2147
Mailing Address - Fax:530-527-2410
Practice Address - Street 1:2060 MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-2373
Practice Address - Country:US
Practice Address - Phone:530-527-2147
Practice Address - Fax:530-527-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice