MEDICARE: MOODY DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12011396A	IN

General Provider Information

NPI Number	:	1396110508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOODY DENTAL LLC

Provider Business Mailing Address
First Line	:	13955 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5591
Fax Number	:	219-374-5592

Provider Business Practice Location Address
First Line	:	13955 MORSE ST
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-9639
Country	:	US
Telephone Number	:	219-374-5591
Fax Number	:	219-374-5592

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. MOODY WASIF
Credential	:	D.M.D
Telephone Number	:	219-322-6892

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	12/14/2015

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