Provider Demographics
NPI:1538382395
Name:MOODY, PETER JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
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 1:5385 CONROY RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3719
Mailing Address - Country:US
Mailing Address - Phone:407-839-4822
Mailing Address - Fax:
Practice Address - Street 1:5385 CONROY RD
Practice Address - Street 2:SUITE #101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-3719
Practice Address - Country:US
Practice Address - Phone:407-839-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL85811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice