Provider Demographics
NPI:1912073941
Name:MOODY, DANA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:A
Last Name:MOODY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY WEST
Mailing Address - Street 2:SUITE 972A
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-277-4388
Mailing Address - Fax:618-277-4388
Practice Address - Street 1:2900 FRANK SCOTT PKWY WEST
Practice Address - Street 2:SUITE 972A
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-277-4388
Practice Address - Fax:618-277-4388
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice