Provider Demographics
NPI:1528141918
Name:MOON, MYUNG SOOK (DMD)
Entity type:Individual
Prefix:
First Name:MYUNG SOOK
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MYUNG SOOK
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:12510 QUEENS BLVD STE 219
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1506
Mailing Address - Country:US
Mailing Address - Phone:718-897-6453
Mailing Address - Fax:718-268-0105
Practice Address - Street 1:12510 QUEENS BLVD STE 219
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1506
Practice Address - Country:US
Practice Address - Phone:718-897-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist