1336420165 NPI number — DR. HONG BEOM MOON DDS, MS, FICD

Table of content: DR. HONG BEOM MOON DDS, MS, FICD (NPI 1336420165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336420165 NPI number — DR. HONG BEOM MOON DDS, MS, FICD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
HONG
Provider Middle Name:
BEOM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS, FICD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336420165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 WILSHIRE BLVD STE 770
Provider Second Line Business Mailing Address:
SMILE WORLD ORTHODONTICS
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90010-3008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-365-2828
Provider Business Mailing Address Fax Number:
213-365-2822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 WILSHIRE BLVD STE 770
Provider Second Line Business Practice Location Address:
SMILE WORLD ORTHODONTICS
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90010-3008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-365-2828
Provider Business Practice Location Address Fax Number:
213-365-2822
Provider Enumeration Date:
09/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  38095 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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