Healthcare Provider Details

I. General information

NPI: 1932976404
Provider Name (Legal Business Name): JUAN MANUEL MOYA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9737 AERO DR STE 210
SAN DIEGO CA
92123-1854
US

IV. Provider business mailing address

3885 HIDDEN TRAIL DR
JAMUL CA
91935-2113
US

V. Phone/Fax

Practice location:
  • Phone: 858-336-8478
  • Fax:
Mailing address:
  • Phone: 619-772-6333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS109147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: