Provider Demographics
NPI:1801395538
Name:MOON, EUN SANG (DDS)
Entity Type:Individual
Prefix:
First Name:EUN SANG
Middle Name:
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 1:85-60HO, SANGBONG-DONG
Mailing Address - Street 2:
Mailing Address - City:SEOUL
Mailing Address - State:JUNGRANG-GU
Mailing Address - Zip Code:02152
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-701-8648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0247281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30.024728Medicaid