Provider Demographics
NPI:1780917823
Name:MOODY, BEAU G (DMD)
Entity type:Individual
Prefix:DR
First Name:BEAU
Middle Name:G
Last Name:MOODY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 LINDENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2580
Mailing Address - Country:US
Mailing Address - Phone:618-659-0456
Mailing Address - Fax:
Practice Address - Street 1:1811 LINDENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2580
Practice Address - Country:US
Practice Address - Phone:618-659-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist