Provider Demographics
NPI:1700220894
Name:MOON, SORA (DMD)
Entity Type:Individual
Prefix:
First Name:SORA
Middle Name:
Last Name:MOON
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 1:3480 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:
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:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65353122300000X
NMDD39141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice