Provider Demographics
NPI:1669920591
Name:MOODY, EDWARD MORRIS III (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MORRIS
Last Name:MOODY
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 E TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:RAYNE
Mailing Address - State:LA
Mailing Address - Zip Code:70578-6435
Mailing Address - Country:US
Mailing Address - Phone:337-334-2967
Mailing Address - Fax:337-334-2967
Practice Address - Street 1:404 E TEXAS AVE
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-6435
Practice Address - Country:US
Practice Address - Phone:337-334-2967
Practice Address - Fax:337-334-2967
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA54901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice