Provider Demographics
NPI:1962037523
Name:BEVERLY MOON DMD LLC
Entity Type:Organization
Organization Name:BEVERLY MOON DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-754-1998
Mailing Address - Street 1:16424 LUCILLE ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-7032
Mailing Address - Country:US
Mailing Address - Phone:732-754-1998
Mailing Address - Fax:
Practice Address - Street 1:4601 W 109TH ST STE 240
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1323
Practice Address - Country:US
Practice Address - Phone:913-338-3384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental