Provider Demographics
NPI:1437256948
Name:FORREST L MOUDY DDS PA INC
Entity Type:Organization
Organization Name:FORREST L MOUDY DDS PA INC
Other - Org Name:FORREST L MOUDY DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOUDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-495-2115
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0878
Mailing Address - Country:US
Mailing Address - Phone:479-495-2115
Mailing Address - Fax:479-495-2267
Practice Address - Street 1:105 E 10TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-0878
Practice Address - Country:US
Practice Address - Phone:479-495-2115
Practice Address - Fax:479-495-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR20301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58359OtherBLUE CROSS BLUE SHIELD
AR846563OtherUNITED CONCORDIA