Provider Demographics
NPI:1760739825
Name:MOODY, MICHAEL S (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MOODY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 N DURANGO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-3916
Mailing Address - Country:US
Mailing Address - Phone:801-915-4554
Mailing Address - Fax:
Practice Address - Street 1:6200 N DURANGO DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149
Practice Address - Country:US
Practice Address - Phone:702-660-5574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ94331223S0112X
FLDRP1048390200000X
NVS2-155C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program