Provider Demographics
NPI:1346317757
Name:JUSTIN MOODY PC
Entity Type:Organization
Organization Name:JUSTIN MOODY PC
Other - Org Name:HORIZON WEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-716-5622
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:NE
Mailing Address - Zip Code:69339-0488
Mailing Address - Country:US
Mailing Address - Phone:308-665-2025
Mailing Address - Fax:308-665-1506
Practice Address - Street 1:705 FIRST STREET
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:NE
Practice Address - Zip Code:69339-0488
Practice Address - Country:US
Practice Address - Phone:308-665-2025
Practice Address - Fax:308-665-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty