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General NPI Number Information
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NPI Number | 1790970614
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Entity Type | Organization
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Legal Business Name | MOON ROAD COSMETIC & FAMILY DENTISTRY
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Dates
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Enumeration Date | 09/13/2007
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 7209 MOON RD
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City | COLUMBUS
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State | GA
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Zip | 31909-1798
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Country | US
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Telephone | 706-243-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 7209 MOON RD
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City | COLUMBUS
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State | GA
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Zip | 31909-1798
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Country | US
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Telephone | 706-243-3000
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DAYO OBEBE
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Credential | DMD
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Telephone | 706-243-3000
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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 | 011235
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 011235
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License Number State | GA
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