Provider Demographics
NPI:1619118874
Name:MOON, PAM CLEERE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:PAM
Middle Name:CLEERE
Last Name:MOON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7129 DOUGLAS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76182-7702
Mailing Address - Country:US
Mailing Address - Phone:817-905-6086
Mailing Address - Fax:
Practice Address - Street 1:7713 SAND ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118
Practice Address - Country:US
Practice Address - Phone:817-589-7374
Practice Address - Fax:817-589-9037
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice