Healthcare Provider Details

I. General information

NPI: 1154481075
Provider Name (Legal Business Name): WILLIAM A MOON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 BAKER AVE EAST
HAINES CITY FL
33844-4325
US

IV. Provider business mailing address

1290 GOLFVIEW AVE ATTN: ACCOUNTS RECEIVABLE
BARTOW FL
33830-6740
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-3252
  • Fax: 863-419-3497
Mailing address:
  • Phone: 863-519-7900
  • Fax: 863-519-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN7469
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: