Provider Demographics
NPI:1396769006
Name:MOODY, EDWARD HERBERT JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HERBERT
Last Name:MOODY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:920 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-4515
Mailing Address - Country:US
Mailing Address - Phone:423-587-1421
Mailing Address - Fax:423-587-6092
Practice Address - Street 1:920 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-4515
Practice Address - Country:US
Practice Address - Phone:423-587-1421
Practice Address - Fax:423-587-6092
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS44471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry