Provider Demographics
NPI:1225202138
Name:BRENT W. MOODY D.D.S., PC
Entity Type:Organization
Organization Name:BRENT W. MOODY D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-755-8020
Mailing Address - Street 1:4320 MCAULEY BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8386
Mailing Address - Country:US
Mailing Address - Phone:405-755-8020
Mailing Address - Fax:
Practice Address - Street 1:4320 MCAULEY BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8386
Practice Address - Country:US
Practice Address - Phone:405-755-8020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty