Provider Demographics
NPI:1720526593
Name:ELLIS MOON ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:ELLIS MOON ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:281-485-6003
Mailing Address - Street 1:2015 BROADWAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5698
Mailing Address - Country:US
Mailing Address - Phone:281-485-6003
Mailing Address - Fax:281-485-3376
Practice Address - Street 1:2015 BROADWAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5698
Practice Address - Country:US
Practice Address - Phone:281-485-6003
Practice Address - Fax:281-485-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX154041223X0400X
TX281701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty