Healthcare Provider Details

I. General information

NPI: 1841696184
Provider Name (Legal Business Name): WILLIAM HEATH MOODY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 COUNTY ROAD 554
ATHENS TN
37303-6420
US

IV. Provider business mailing address

2702 STELLATTA CV NW
CLEVELAND TN
37312-2473
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-7431
  • Fax:
Mailing address:
  • Phone: 770-639-3829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9941
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: