Provider Demographics
NPI:1992835151
Name:MOODY, GEORGE TERRANCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:TERRANCE
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:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1004
Mailing Address - Country:US
Mailing Address - Phone:662-226-0554
Mailing Address - Fax:662-226-0556
Practice Address - Street 1:1450 OAK ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4600
Practice Address - Country:US
Practice Address - Phone:662-226-0554
Practice Address - Fax:662-226-0556
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2090-841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060069Medicaid