1184724411 NPI number — KRISTOPHER JOE MOON D.D.S

Table of content: KRISTOPHER JOE MOON D.D.S (NPI 1184724411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184724411 NPI number — KRISTOPHER JOE MOON D.D.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
KRISTOPHER
Provider Middle Name:
JOE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.D.S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184724411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3718 TEMPLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANVEL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77578-2912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-436-3444
Provider Business Mailing Address Fax Number:
713-436-7442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2803 BUSINESS CENTER DR.
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
PEARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-436-3444
Provider Business Practice Location Address Fax Number:
713-436-7442
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  20225 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 20225 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 164702601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".