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General NPI Number Information
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NPI Number | 1205657020
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Entity Type | Organization
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Legal Business Name | JUSTIN MOODY, DDS, P.C.
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Dates
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Enumeration Date | 10/23/2024
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 1540 COOPER POINT RD SW STE 450
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City | OLYMPIA
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State | WA
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Zip | 98502-1033
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Country | US
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Telephone | 360-357-9919
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Fax |
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Provider Business Mailing Address
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Address Line | 1540 COOPER POINT RD SW STE 450
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City | OLYMPIA
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State | WA
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Zip | 98502-1033
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Country | US
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Telephone | 360-357-9919
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Fax |
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Authorized Official
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Title or Position | MANAGING DENTIST
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Name | RICHARD BUCK
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Credential | DMD
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Telephone | 360-357-9919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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