1124409552 NPI number — MODERN DENTAL PROFESIONALS CO PC

Table of content: (NPI 1124409552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124409552 NPI number — MODERN DENTAL PROFESIONALS CO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESIONALS CO PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124409552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25153
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92799-5153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-578-6358
Provider Business Mailing Address Fax Number:
949-242-2631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 FOUNDERS PKWY # A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE ROCK
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80104-7528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-688-0252
Provider Business Practice Location Address Fax Number:
303-660-9872
Provider Enumeration Date:
06/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MELLOR
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
PC OWNER
Authorized Official Telephone Number:
303-209-2250

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  105734 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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