Provider Demographics
NPI:1538512421
Name:JAKE MODERY, D.D.S., P.C.
Entity Type:Organization
Organization Name:JAKE MODERY, D.D.S., P.C.
Other - Org Name:MODERY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MODERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-731-1180
Mailing Address - Street 1:5902 S FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79118-8807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 TOWN SQUARE BLVD
Practice Address - Street 2:SUITE 1090
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-1250
Practice Address - Country:US
Practice Address - Phone:806-731-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30983122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty