Provider Demographics
NPI:1538398813
Name:WASIF, MOODY (DDS)
Entity type:Individual
Prefix:
First Name:MOODY
Middle Name:
Last Name:WASIF
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 1:225 WA SEH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781-9490
Mailing Address - Country:US
Mailing Address - Phone:906-643-8689
Mailing Address - Fax:906-643-6716
Practice Address - Street 1:225 WA SEH ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-9490
Practice Address - Country:US
Practice Address - Phone:906-643-8689
Practice Address - Fax:906-643-6716
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010200681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice