Provider Demographics
NPI:1851887012
Name:MOON, SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
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 1:2426 W 8TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3872
Mailing Address - Country:US
Mailing Address - Phone:213-381-3900
Mailing Address - Fax:
Practice Address - Street 1:2426 W. 8TH ST. #209
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057
Practice Address - Country:US
Practice Address - Phone:213-381-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist