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General NPI Number Information
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NPI Number | 1881645166
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Entity Type | Individual
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Provider Name | STACY JERALD MOON DDS
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Gender | Male
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 07/06/2023
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Provider Practice Location Address
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Address Line | 4266 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-0726
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Country | US
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Telephone | 208-939-7053
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Fax | 208-938-6032
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Provider Business Mailing Address
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Address Line | 3550 N BROOKSIDE LN
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City | BOISE
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State | ID
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Zip | 83714-9705
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Country | US
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Telephone | 208-908-1793
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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 | D3387
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License Number State | ID
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