Provider Demographics
NPI:1194577171
Name:DR. JUSTIN MOODY, PLLC
Entity type:Organization
Organization Name:DR. JUSTIN MOODY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-752-6349
Mailing Address - Street 1:2501 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2540
Mailing Address - Country:US
Mailing Address - Phone:253-752-6349
Mailing Address - Fax:
Practice Address - Street 1:2501 N PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2540
Practice Address - Country:US
Practice Address - Phone:253-752-6349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty