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General NPI Number Information
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NPI Number | 1205217445
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Entity Type | Individual
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Provider Name | JAKE MODERY D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/13/2015
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 9200 TOWN SQUARE BLVD SUITE 1090
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City | AMARILLO
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State | TX
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Zip | 79119-1250
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Country | US
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Telephone | 806-731-1180
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Fax | 806-414-4680
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Provider Business Mailing Address
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Address Line | 5902 S FANNIN ST
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City | AMARILLO
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State | TX
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Zip | 79118-8807
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Country | US
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Telephone | 806-731-1180
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Fax | 806-414-4680
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30983
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License Number State | TX
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