Provider Demographics
NPI:1750707097
Name:MOUDY, FORREST
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:
Last Name:MOUDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0878
Mailing Address - Country:US
Mailing Address - Phone:479-495-2115
Mailing Address - Fax:479-495-2267
Practice Address - Street 1:105 E 10TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-0878
Practice Address - Country:US
Practice Address - Phone:479-495-2115
Practice Address - Fax:479-495-2267
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR20301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106597608Medicaid