1386828812 NPI number — MODERN DENTAL PROFESSIONALS-LEE,INC

Table of content: (NPI 1386828812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386828812 NPI number — MODERN DENTAL PROFESSIONALS-LEE,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESSIONALS-LEE,INC
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:
MONARCH DENTAL
Provider Other Organization Name Type Code:
3
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:
1386828812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1475 UPPER VALLEY PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45504-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-322-7549
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 UPPER VALLEY PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45504-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-322-7549
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
DISTRICT MANAGER
Authorized Official Telephone Number:
937-278-7956

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30.019758 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2181419 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".