Provider Demographics
NPI:1588068399
Name:MOODY, COREY BRENT (DDS)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:BRENT
Last Name:MOODY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3424 FOX HOUND RUN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-1605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:857 COLLIER RD NW STE 5A-5B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2532
Practice Address - Country:US
Practice Address - Phone:404-689-4140
Practice Address - Fax:404-689-4142
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0149241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics