MEDICARE: WILLIAM A MOON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	DN7469	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN7469	OTHER		LICENSE

General Provider Information

NPI Number	:	1154481075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM A MOON DDS

Provider Business Mailing Address
First Line	:	1290 GOLFVIEW AVE
Second Line	:	ATTN: ACCOUNTS RECEIVABLE
City	:	BARTOW
State	:	FL
Zip	:	33830-6740
Country	:	US
Telephone Number	:	863-519-7900
Fax Number	:	863-519-7696

Provider Business Practice Location Address
First Line	:	1700 BAKER AVE EAST
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-4325
Country	:	US
Telephone Number	:	863-419-3252
Fax Number	:	863-419-3497

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	02/26/2013

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Directions to “ WILLIAM A MOON DDS” Practice Location

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