Provider Demographics
NPI:1992716252
Name:MOAN, MARK (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOAN
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 1:51 SAYBRIDGE MANOR PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1806
Mailing Address - Country:US
Mailing Address - Phone:636-949-2587
Mailing Address - Fax:
Practice Address - Street 1:1032 RONDALE CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7368
Practice Address - Country:US
Practice Address - Phone:636-949-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001615641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice