Healthcare Provider Details

I. General information

NPI: 1265624712
Provider Name (Legal Business Name): ROBERT M MOODYDDS/ EUREKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W 3RD ST
EUREKA KS
67045-1404
US

IV. Provider business mailing address

302 W 3RD ST
EUREKA KS
67045-1404
US

V. Phone/Fax

Practice location:
  • Phone: 620-583-7489
  • Fax: 620-583-7489
Mailing address:
  • Phone: 620-583-7489
  • Fax: 620-583-7489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT M MOODY
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 620-583-7489