MEDICARE: MR. BRADLEY MOON

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	1223G0001X	General Practice Dentistry	1201-4426A	IN

General Provider Information

NPI Number	:	1326811167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY MOON

Provider Business Mailing Address
First Line	:	8602 E 10TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-5443
Country	:	US
Telephone Number	:	309-269-0390
Fax Number	:

Provider Business Practice Location Address
First Line	:	8602 E 10TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-5443
Country	:	US
Telephone Number	:	309-269-0390
Fax Number	:

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

Provider Enumeration Date	:	11/02/2023
Last Update Date	:	03/18/2026

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Directions to “ MR. BRADLEY MOON ” Practice Location

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