Healthcare Provider Details

I. General information

NPI: 1720073166
Provider Name (Legal Business Name): THOMAS FRANCIS MOONEY III DDS, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9018 PHOENIX PKWY
O FALLON MO
63368-4278
US

IV. Provider business mailing address

9018 PHOENIX PKWY
O FALLON MO
63368-4278
US

V. Phone/Fax

Practice location:
  • Phone: 636-970-4700
  • Fax:
Mailing address:
  • Phone: 636-970-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number015486
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: