Provider Demographics
NPI:1730569856
Name:MOON, KYUNGSIK
Entity type:Individual
Prefix:
First Name:KYUNGSIK
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22301 ROCKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1509
Mailing Address - Country:US
Mailing Address - Phone:440-232-4222
Mailing Address - Fax:440-374-5279
Practice Address - Street 1:22301 ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-1509
Practice Address - Country:US
Practice Address - Phone:440-232-4222
Practice Address - Fax:440-374-5279
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0245061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice