Provider Demographics
NPI:1548418940
Name:MOON, JOE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
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 1:16424 LUCILLE ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-7032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16424 LUCILLE ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-7032
Practice Address - Country:US
Practice Address - Phone:215-432-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS608221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics