Provider Demographics
NPI:1912119728
Name:MOODY, DENNIS MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MICHAEL
Last Name:MOODY
Suffix:
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 1:7341 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5900
Mailing Address - Country:US
Mailing Address - Phone:330-726-1152
Mailing Address - Fax:330-758-7845
Practice Address - Street 1:7341 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5900
Practice Address - Country:US
Practice Address - Phone:330-726-1152
Practice Address - Fax:330-758-7845
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0154841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
341290190OtherT.I.N.