=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487710190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOODY FAMILY DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 01/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E SCHOOL HOUSE LANE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-848-6446
-----------------------------------------------------
Fax | 215-848-7202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E SCHOOL HOUSE LANE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-848-6446
-----------------------------------------------------
Fax | 215-848-7202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. IRIS L LEWIS MOODY
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 215-848-6446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS23581L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS024507L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------