MEDICARE: CHARON MOODY RDHAP

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	125K00000X	Advanced Practice Dental Therapist	723	CA

General Provider Information

NPI Number	:	1558828160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARON MOODY RDHAP

Provider Business Mailing Address
First Line	:	727 E HOLBORN DR
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90746-2328
Country	:	US
Telephone Number	:	213-591-0807
Fax Number	:

Provider Business Practice Location Address
First Line	:	727 E HOLBORN DR
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90746-2328
Country	:	US
Telephone Number	:	213-591-0807
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2019
Last Update Date	:	03/01/2019

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Directions to “ CHARON MOODY RDHAP” Practice Location

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