Provider Demographics
NPI:1760733562
Name:MOODY, MEGAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 MALLET HILL RD
Mailing Address - Street 2:APT. 11206
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4471
Mailing Address - Country:US
Mailing Address - Phone:706-832-0746
Mailing Address - Fax:
Practice Address - Street 1:3901 EDMUND HWY
Practice Address - Street 2:SUITE C
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-1900
Practice Address - Country:US
Practice Address - Phone:803-755-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC80801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice