Healthcare Provider Details

I. General information

NPI: 1750721486
Provider Name (Legal Business Name): JOSEPH J MOON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2756 S. ELM AVENUE ELM DENTAL CENTER
FRESNO CA
93706
US

IV. Provider business mailing address

2756 S. ELM AVENUE ELM DENTAL CENTER
FRESNO CA
93706
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-5345
  • Fax:
Mailing address:
  • Phone: 559-457-5345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: