Provider Demographics
NPI:1518372580
Name:MOONEY, MIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:
Last Name:MOONEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 COBALT LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5304
Mailing Address - Country:US
Mailing Address - Phone:517-881-6593
Mailing Address - Fax:
Practice Address - Street 1:179 VERBENA DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-4505
Practice Address - Country:US
Practice Address - Phone:254-778-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice