Provider Demographics
NPI:1386739720
Name:MOONEY, JOHN T (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:MOONEY
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 1:2645 SUMMERS WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0000
Mailing Address - Country:US
Mailing Address - Phone:208-233-8015
Mailing Address - Fax:
Practice Address - Street 1:333 WEST CEDAR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-0000
Practice Address - Country:US
Practice Address - Phone:208-233-6912
Practice Address - Fax:208-233-6921
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-14861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice