Provider Demographics
NPI:1649524414
Name:MOON, ANGELA (DMD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 COMMONWEALTH AVE APT 27
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3612
Mailing Address - Country:US
Mailing Address - Phone:248-505-5290
Mailing Address - Fax:
Practice Address - Street 1:367 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2730
Practice Address - Country:US
Practice Address - Phone:617-208-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist