Provider Demographics
NPI:1205657020
Name:JUSTIN MOODY, DDS, P.C.
Entity type:Organization
Organization Name:JUSTIN MOODY, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-357-9919
Mailing Address - Street 1:1540 COOPER POINT RD SW STE 450
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1033
Mailing Address - Country:US
Mailing Address - Phone:360-357-9919
Mailing Address - Fax:
Practice Address - Street 1:1540 COOPER POINT RD SW STE 450
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1033
Practice Address - Country:US
Practice Address - Phone:360-357-9919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty