Provider Demographics
NPI:1295987451
Name:MOON, DAEUK
Entity type:Individual
Prefix:DR
First Name:DAEUK
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2901
Mailing Address - Country:US
Mailing Address - Phone:215-487-2347
Mailing Address - Fax:215-487-1459
Practice Address - Street 1:8115 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2901
Practice Address - Country:US
Practice Address - Phone:215-487-2347
Practice Address - Fax:215-487-1459
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist