Healthcare Provider Details

I. General information

NPI: 1336677665
Provider Name (Legal Business Name): YONGHWI MOON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 GRAND AVE
WAUKEGAN IL
60085
US

IV. Provider business mailing address

1009 HILLDALE LN
BUFFALO GROVE IL
60089-7017
US

V. Phone/Fax

Practice location:
  • Phone: 847-662-4400
  • Fax:
Mailing address:
  • Phone: 585-683-0248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019031432
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: