Provider Demographics
NPI:1336871995
Name:MOON, MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 CLOVERLEAF PL
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-3421
Mailing Address - Country:US
Mailing Address - Phone:214-713-9759
Mailing Address - Fax:
Practice Address - Street 1:2611 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-6518
Practice Address - Country:US
Practice Address - Phone:580-622-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice