Healthcare Provider Details

I. General information

NPI: 1023025939
Provider Name (Legal Business Name): JON Y. MOODY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S MAIN #3
FILLMORE UT
84631
US

IV. Provider business mailing address

55 S MAIN #3
FILLMORE UT
84631
US

V. Phone/Fax

Practice location:
  • Phone: 435-743-6178
  • Fax: 435-743-6178
Mailing address:
  • Phone: 435-743-6178
  • Fax: 435-743-6178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number02670-0701-7
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: