Provider Demographics
NPI:1740202852
Name:EDWARD H MOODY JR DDS PC
Entity Type:Organization
Organization Name:EDWARD H MOODY JR DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-587-1421
Mailing Address - Street 1:920 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-4515
Mailing Address - Country:US
Mailing Address - Phone:423-587-1421
Mailing Address - Fax:423-587-6092
Practice Address - Street 1:920 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-4515
Practice Address - Country:US
Practice Address - Phone:423-587-1421
Practice Address - Fax:423-587-6092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS44471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty