Healthcare Provider Details

I. General information

NPI: 1104714757
Provider Name (Legal Business Name): SALLY JO MOON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 US HIGHWAY 301 N
PARRISH FL
34219-8675
US

IV. Provider business mailing address

212 SNYDER AVE
ANN ARBOR MI
48103-5563
US

V. Phone/Fax

Practice location:
  • Phone: 774-246-9347
  • Fax:
Mailing address:
  • Phone: 616-322-5587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: