Provider Demographics
NPI:1558828160
Name:MOODY, CHARON (RDHAP)
Entity Type:Individual
Prefix:
First Name:CHARON
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 E HOLBORN DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2328
Mailing Address - Country:US
Mailing Address - Phone:213-591-0807
Mailing Address - Fax:
Practice Address - Street 1:727 E HOLBORN DR
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-2328
Practice Address - Country:US
Practice Address - Phone:213-591-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA723125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist