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General NPI Number Information
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NPI Number | 1104714757
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Entity Type | Individual
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Provider Name | SALLY JO MOON DDS
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Gender | Female
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Dates
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Enumeration Date | 06/24/2025
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 11225 US HIGHWAY 301 N
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City | PARRISH
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State | FL
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Zip | 34219-8675
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Country | US
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Telephone | 774-246-9347
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Fax |
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Provider Business Mailing Address
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Address Line | 212 SNYDER AVE
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City | ANN ARBOR
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State | MI
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Zip | 48103-5563
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Country | US
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Telephone | 616-322-5587
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN30240
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License Number State | FL
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