Provider Demographics
NPI:1760406672
Name:MOON, J D (DDS)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:D
Last Name:MOON
Suffix:
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 1:2002 N FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-2808
Mailing Address - Country:US
Mailing Address - Phone:563-391-2212
Mailing Address - Fax:563-391-1545
Practice Address - Street 1:2002 N FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-2808
Practice Address - Country:US
Practice Address - Phone:563-391-2212
Practice Address - Fax:563-391-1545
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice