Provider Demographics
NPI:1023329620
Name:BRIAN P. MOODY, DDS, PLLC
Entity type:Organization
Organization Name:BRIAN P. MOODY, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-285-1338
Mailing Address - Street 1:4055 21ST AVE W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-1247
Mailing Address - Country:US
Mailing Address - Phone:206-285-1338
Mailing Address - Fax:206-285-4665
Practice Address - Street 1:4055 21ST AVE W
Practice Address - Street 2:SUITE 101
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-1247
Practice Address - Country:US
Practice Address - Phone:206-285-1338
Practice Address - Fax:206-285-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty