Provider Demographics
NPI:1881645166
Name:MOON, STACY JERALD (DDS)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:JERALD
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 1:3550 N BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9705
Mailing Address - Country:US
Mailing Address - Phone:208-908-1793
Mailing Address - Fax:
Practice Address - Street 1:4266 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0726
Practice Address - Country:US
Practice Address - Phone:208-939-7053
Practice Address - Fax:208-938-6032
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID820527796OtherIRS