Provider Demographics
NPI:1851554737
Name:STACY J. MOON DDS, PA
Entity Type:Organization
Organization Name:STACY J. MOON DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:JERALD
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-939-7053
Mailing Address - Street 1:6019 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0997
Mailing Address - Country:US
Mailing Address - Phone:208-939-7053
Mailing Address - Fax:208-938-6032
Practice Address - Street 1:6019 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-939-7053
Practice Address - Fax:208-938-6032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3387261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental