MEDICARE: KYUNGSIK 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	30-024506	OH

General Provider Information

NPI Number	:	1730569856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYUNGSIK MOON

Provider Business Mailing Address
First Line	:	22301 ROCKSIDE RD
Second Line	:
City	:	BEDFORD
State	:	OH
Zip	:	44146-1509
Country	:	US
Telephone Number	:	440-232-4222
Fax Number	:	440-374-5279

Provider Business Practice Location Address
First Line	:	22301 ROCKSIDE RD
Second Line	:
City	:	BEDFORD
State	:	OH
Zip	:	44146-1509
Country	:	US
Telephone Number	:	440-232-4222
Fax Number	:	440-374-5279

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

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	06/03/2015

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Directions to “ KYUNGSIK MOON ” Practice Location

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