Provider Demographics
NPI:1093799819
Name:MOODY, CAROLYN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:S
Last Name:MOODY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2004
Mailing Address - Country:US
Mailing Address - Phone:859-236-8448
Mailing Address - Fax:859-239-8909
Practice Address - Street 1:303 S 4TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2004
Practice Address - Country:US
Practice Address - Phone:859-236-8448
Practice Address - Fax:859-239-8909
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5693122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45601101Medicaid
KY60056934Medicaid