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General NPI Number Information
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NPI Number | 1528693926
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Entity Type | Organization
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Legal Business Name | MOODY HANAHAN DENTISTRY LLC
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Dates
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Enumeration Date | 03/05/2020
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Last Update Date | 03/06/2020
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Provider Practice Location Address
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Address Line | 4119 HUMBERT RD
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City | ALTON
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State | IL
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Zip | 62002-7116
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Country | US
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Telephone | 314-477-1777
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Fax | 618-462-3530
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Provider Business Mailing Address
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Address Line | 4119 HUMBERT RD
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City | ALTON
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State | IL
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Zip | 62002-7116
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Country | US
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Telephone | 314-477-1777
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Fax | 618-462-3530
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Authorized Official
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Title or Position | OWNER
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Name | SARA HANAHAN
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Credential | DMD
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Telephone | 618-465-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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