Provider Demographics
NPI:1205217445
Name:MODERY, JAKE (DDS)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MODERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 S FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79118-8807
Mailing Address - Country:US
Mailing Address - Phone:806-731-1180
Mailing Address - Fax:806-414-4680
Practice Address - Street 1:9200 TOWN SQUARE BLVD
Practice Address - Street 2:SUITE 1090
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-1250
Practice Address - Country:US
Practice Address - Phone:806-731-1180
Practice Address - Fax:806-414-4680
Is Sole Proprietor?:No
Enumeration Date:2015-06-13
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist