Provider Demographics
NPI:1043280985
Name:MOODY, REX C (DSS)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:C
Last Name:MOODY
Suffix:
Gender:M
Credentials:DSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-760-1600
Mailing Address - Fax:949-760-0911
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 402
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-760-1600
Practice Address - Fax:949-760-0911
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA241481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT08566Medicare UPIN