Provider Demographics
NPI:1134240534
Name:MOODY, STANSON (DMD)
Entity type:Individual
Prefix:DR
First Name:STANSON
Middle Name:
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 1:747 AQUIDNECK AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7265
Mailing Address - Country:US
Mailing Address - Phone:401-846-9660
Mailing Address - Fax:401-846-9667
Practice Address - Street 1:747 AQUIDNECK AVE STE 203
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7265
Practice Address - Country:US
Practice Address - Phone:401-846-9660
Practice Address - Fax:401-846-9667
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI16531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice