Healthcare Provider Details

I. General information

NPI: 1598767345
Provider Name (Legal Business Name): ROBERT MICHAEL MOODY D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 08/09/2007
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 Number5279
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: