Provider Demographics
NPI:1033204094
Name:MOODY, MICHAEL DERRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DERRICK
Last Name:MOODY
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:9990 W 26TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1581
Mailing Address - Country:US
Mailing Address - Phone:303-232-4422
Mailing Address - Fax:303-232-8795
Practice Address - Street 1:215 SE HOWARD AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2204
Practice Address - Country:US
Practice Address - Phone:918-333-9155
Practice Address - Fax:918-333-9142
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2024-04-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK72891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery