=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902011307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIMMY JOE MOON, DDS & BARBARA SEID MOON, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2009 JOHN ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77502-3375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-473-6677
-----------------------------------------------------
Fax | 713-473-6778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2009 JOHN ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77502-3375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-473-6677
-----------------------------------------------------
Fax | 713-473-6778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JIMMY JOE MOON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 713-473-6677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 13002
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 13206
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------