Provider Demographics
NPI:1154558831
Name:MOON, BEVERLY (DMD)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:MOULIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1608 S GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-3966
Mailing Address - Country:US
Mailing Address - Phone:732-754-1998
Mailing Address - Fax:
Practice Address - Street 1:5550 HEDGE LANE TER
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-2253
Practice Address - Country:US
Practice Address - Phone:913-422-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS608241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice