Provider Demographics
NPI:1689128746
Name:BRIAN MOODY, DDS, PLLC
Entity Type:Organization
Organization Name:BRIAN MOODY, DDS, PLLC
Other - Org Name:CREEKSIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-485-0300
Mailing Address - Street 1:19214 BOTHELL WAY NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-6066
Mailing Address - Country:US
Mailing Address - Phone:425-485-0300
Mailing Address - Fax:
Practice Address - Street 1:19214 BOTHELL WAY NE
Practice Address - Street 2:SUITE C
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-6066
Practice Address - Country:US
Practice Address - Phone:425-485-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty