Provider Demographics
NPI:1639660806
Name:MOODY, DEVAN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEVAN
Middle Name:WILLIAM
Last Name:MOODY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 E LITTLE TURTLE WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8343
Mailing Address - Country:US
Mailing Address - Phone:907-750-0257
Mailing Address - Fax:
Practice Address - Street 1:308 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-7348
Practice Address - Country:US
Practice Address - Phone:989-631-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty