Provider Demographics
NPI:1124302930
Name:MOODY, DEANA LANE (DDS)
Entity type:Individual
Prefix:DR
First Name:DEANA
Middle Name:LANE
Last Name:MOODY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 ALTAMONT PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-3023
Mailing Address - Country:US
Mailing Address - Phone:240-349-2158
Mailing Address - Fax:240-349-2158
Practice Address - Street 1:4255 ALTAMONT PL
Practice Address - Street 2:SUITE 204
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3023
Practice Address - Country:US
Practice Address - Phone:240-349-2158
Practice Address - Fax:240-349-2158
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD115721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice