Provider Demographics
NPI:1184724411
Name:MOON, KRISTOPHER JOE (DDS)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:JOE
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 1:3718 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2912
Mailing Address - Country:US
Mailing Address - Phone:713-436-3444
Mailing Address - Fax:713-436-7442
Practice Address - Street 1:2803 BUSINESS CENTER DR.
Practice Address - Street 2:SUITE 121
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584
Practice Address - Country:US
Practice Address - Phone:713-436-3444
Practice Address - Fax:713-436-7442
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20225122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164702601Medicaid
TXU99632Medicare UPIN
TX164702601Medicaid