Provider Demographics
NPI:1710147087
Name:DARREL AND ROSEANN MOONEY
Entity Type:Organization
Organization Name:DARREL AND ROSEANN MOONEY
Other - Org Name:IDAHO PROSTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNWE
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:LAVERNE
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-841-5038
Mailing Address - Street 1:347 CROOKED EAR CT
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-9477
Mailing Address - Country:US
Mailing Address - Phone:208-841-5038
Mailing Address - Fax:
Practice Address - Street 1:1323 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1747
Practice Address - Country:US
Practice Address - Phone:208-263-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1650PR1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty