Provider Demographics
NPI:1427064567
Name:MOODT, JAMES WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
Last Name:MOODT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24700 CENTER RIDGE RD
Mailing Address - Street 2:ONE KING JAMES SOUTH, SUITE #19
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5636
Mailing Address - Country:US
Mailing Address - Phone:440-871-7979
Mailing Address - Fax:440-871-7093
Practice Address - Street 1:24700 CENTER RIDGE RD
Practice Address - Street 2:ONE KING JAMES SOUTH, SUITE #19
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5636
Practice Address - Country:US
Practice Address - Phone:440-871-7979
Practice Address - Fax:440-871-7093
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15830122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT47877Medicare UPIN
OHM00535383Medicare ID - Type Unspecified