Provider Demographics
NPI:1578637641
Name:MOON, JOSEPH THOMAS (DMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:THOMAS
Last Name:MOON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2089 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5940
Mailing Address - Country:US
Mailing Address - Phone:864-297-6700
Mailing Address - Fax:864-297-6012
Practice Address - Street 1:2089 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5940
Practice Address - Country:US
Practice Address - Phone:864-297-6700
Practice Address - Fax:864-297-6012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2373OtherLICENSE NUMBER