Provider Demographics
NPI:1629077839
Name:MOON, JIMMY JOE SR (DDS)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:JOE
Last Name:MOON
Suffix:SR
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 1:2009 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77502-3375
Mailing Address - Country:US
Mailing Address - Phone:713-473-6677
Mailing Address - Fax:713-473-6778
Practice Address - Street 1:2009 JOHN ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-3375
Practice Address - Country:US
Practice Address - Phone:713-473-6677
Practice Address - Fax:713-473-6778
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice