Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 9954 | GA |
NPI | 1043295439 |
---|---|
Provider Name | Dr. Marty George Moon |
First Address | Washington, DC 20307-5400 |
Second Address | Washington, DC 20307-5400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2005 |
Last Update Date | 08/07/2007 |