Provider Demographics
NPI:1730375171
Name:MOON, BRENDEN DELANEY (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENDEN
Middle Name:DELANEY
Last Name:MOON
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 1:671 WABASH AVE
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321
Mailing Address - Country:US
Mailing Address - Phone:217-357-2171
Mailing Address - Fax:217-357-3562
Practice Address - Street 1:671 WABASH AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321
Practice Address - Country:US
Practice Address - Phone:217-357-2171
Practice Address - Fax:217-357-3562
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9202327Medicaid