Provider Demographics
NPI:1801395538
Name:MOON, EUN SANG (DDS)
Entity type:Individual
Prefix:
First Name:EUN SANG
Middle Name:
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 1:85-60HO, SANGBONG-DONG
Mailing Address - Street 2:
Mailing Address - City:SEOUL
Mailing Address - State:JUNGRANG-GU
Mailing Address - Zip Code:02152
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17707 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1967
Practice Address - Country:US
Practice Address - Phone:602-823-9003
Practice Address - Fax:360-282-3907
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0247281223G0001X
WADE613302381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30.024728Medicaid