Provider Demographics
NPI:1821257247
Name:MOODY, ERNEST W JR (DDS)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:W
Last Name:MOODY
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 1:10 E SCHOOL HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2235
Mailing Address - Country:US
Mailing Address - Phone:215-848-6446
Mailing Address - Fax:215-848-7202
Practice Address - Street 1:10 E SCHOOL HOUSE LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2235
Practice Address - Country:US
Practice Address - Phone:215-848-6446
Practice Address - Fax:215-848-7202
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023581L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist