Provider Demographics
NPI:1720396484
Name:MOODY, JUSTIN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:MOODY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:705 1ST ST
Mailing Address - Street 2:PO BOX 488
Mailing Address - City:CRAWFORD
Mailing Address - State:NE
Mailing Address - Zip Code:69339-1186
Mailing Address - Country:US
Mailing Address - Phone:308-665-2025
Mailing Address - Fax:308-665-1506
Practice Address - Street 1:705 1ST ST
Practice Address - Street 2:BOX 488
Practice Address - City:CRAWFORD
Practice Address - State:NE
Practice Address - Zip Code:69339-1186
Practice Address - Country:US
Practice Address - Phone:308-665-2025
Practice Address - Fax:308-665-1506
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE6124122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026079200Medicaid
NE10026079300Medicaid
NE10026079400Medicaid