Provider Demographics
NPI:1558943308
Name:ELLEN SORA MOON, DMD, INC.
Entity Type:Organization
Organization Name:ELLEN SORA MOON, DMD, INC.
Other - Org Name:MOONLIGHT DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-425-4508
Mailing Address - Street 1:3480 TORRANCE BLVD STE 221
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5813
Mailing Address - Country:US
Mailing Address - Phone:310-543-3505
Mailing Address - Fax:855-767-0741
Practice Address - Street 1:3480 TORRANCE BLVD STE 221
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5813
Practice Address - Country:US
Practice Address - Phone:310-425-4508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty