Provider Demographics
NPI:1972749422
Name:MOODY, JEANNIE MARIE (D,MD)
Entity type:Individual
Prefix:DR
First Name:JEANNIE
Middle Name:MARIE
Last Name:MOODY
Suffix:
Gender:F
Credentials:D,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 BASSWOOD BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6900
Mailing Address - Country:US
Mailing Address - Phone:817-348-0910
Mailing Address - Fax:
Practice Address - Street 1:5407 BASSWOOD BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-6900
Practice Address - Country:US
Practice Address - Phone:817-348-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics