Healthcare Provider Details

I. General information

NPI: 1720067481
Provider Name (Legal Business Name): JOHN P MOON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

IV. Provider business mailing address

1 PINCKNEY BLVD
BEAUFORT SC
29902-6122
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-5600
  • Fax:
Mailing address:
  • Phone: 843-228-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016647
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10361
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: