=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386448645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOON DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2025
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8717 S TACOMA WAY
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-588-9951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8717 S TACOMA WAY
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTURIST
-----------------------------------------------------
Name | HYUN KOOK MOON
-----------------------------------------------------
Credential | LD
-----------------------------------------------------
Telephone | 253-999-3032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122400000X
-----------------------------------------------------
Taxonomy Name | Denturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------