Provider Demographics
NPI:1114220647
Name:MODERN DENTAL INCORPORATED
Entity type:Organization
Organization Name:MODERN DENTAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:866-371-5205
Mailing Address - Street 1:1821 N ZARAGOSA
Mailing Address - Street 2:SUITE 207-316
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7912
Mailing Address - Country:US
Mailing Address - Phone:866-371-5205
Mailing Address - Fax:
Practice Address - Street 1:1821 N ZARAGOSA
Practice Address - Street 2:SUITE 207-316
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7912
Practice Address - Country:US
Practice Address - Phone:866-371-5205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-05
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty