Provider Demographics
NPI:1497077523
Name:MOODY, EVAN PAUL (DDS, MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:PAUL
Last Name:MOODY
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 MILLER OAKS DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-3507
Mailing Address - Country:US
Mailing Address - Phone:913-748-9988
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST ORAL & MAXILLOFACIAL SURGERY DEPARTMENT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-2640
Practice Address - Country:US
Practice Address - Phone:904-542-7540
Practice Address - Fax:904-542-7543
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN257521223S0112X, 1223S0112X
MO2014020904282N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program