Provider Demographics
NPI:1871310284
Name:MIKE MOODY LLC
Entity type:Organization
Organization Name:MIKE MOODY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-223-5040
Mailing Address - Street 1:2330 NW FLANDERS ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3460
Mailing Address - Country:US
Mailing Address - Phone:503-223-5040
Mailing Address - Fax:
Practice Address - Street 1:2330 NW FLANDERS ST STE 204
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3460
Practice Address - Country:US
Practice Address - Phone:503-223-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental