Provider Demographics
NPI:1326191883
Name:MOODY, TANYA MONIQUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MONIQUE
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 1:437 BUTTONBUSH CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8199
Mailing Address - Country:US
Mailing Address - Phone:803-736-5932
Mailing Address - Fax:
Practice Address - Street 1:645 SOUTH 7TH STREET
Practice Address - Street 2:
Practice Address - City:MCBEE
Practice Address - State:SC
Practice Address - Zip Code:29101-0366
Practice Address - Country:US
Practice Address - Phone:843-680-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist