MEDICARE: MR. STACY JERALD 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	122300000X	Dentist	D3387	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	820527796	OTHER	ID	IRS

General Provider Information

NPI Number	:	1881645166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STACY JERALD MOON DDS

Provider Business Mailing Address
First Line	:	3550 N BROOKSIDE LN
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83714-9705
Country	:	US
Telephone Number	:	208-908-1793
Fax Number	:

Provider Business Practice Location Address
First Line	:	4266 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0726
Country	:	US
Telephone Number	:	208-939-7053
Fax Number	:	208-938-6032

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	07/06/2023

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