Provider Demographics
NPI:1710008032
Name:ABERNATHY, MOULTON D JR (DDS)
Entity Type:Individual
Prefix:
First Name:MOULTON
Middle Name:D
Last Name:ABERNATHY
Suffix:JR
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 1:61 BOAT DOCK LN
Mailing Address - Street 2:
Mailing Address - City:DECATURVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38329-5458
Mailing Address - Country:US
Mailing Address - Phone:731-852-4764
Mailing Address - Fax:
Practice Address - Street 1:213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2018
Practice Address - Country:US
Practice Address - Phone:731-847-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist