Provider Demographics
NPI:1558776088
Name:MOON, HWI (DDS, MD)
Entity type:Individual
Prefix:
First Name:HWI
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S CARR RD STE 300
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5840
Mailing Address - Country:US
Mailing Address - Phone:425-277-1844
Mailing Address - Fax:
Practice Address - Street 1:601 S CARR RD STE 300
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5840
Practice Address - Country:US
Practice Address - Phone:425-277-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0401061223S0112X, 204E00000X
WADE61286690204E00000X
TXS9191204E00000X
TX34932204E00000X
WAMD61279945204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery