MEDICARE: DR. JEANNIE MARIE MOODY D,M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	24299	TX

General Provider Information

NPI Number	:	1972749422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNIE MARIE MOODY D,M.D

Provider Business Mailing Address
First Line	:	5407 BASSWOOD BLVD
Second Line	:	SUITE 107
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6900
Country	:	US
Telephone Number	:	817-348-0910
Fax Number	:

Provider Business Practice Location Address
First Line	:	5407 BASSWOOD BLVD
Second Line	:	SUITE 107
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6900
Country	:	US
Telephone Number	:	817-348-0910
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2009
Last Update Date	:	01/05/2009

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