Provider Demographics
NPI:1114721909
Name:MODRALL DENTISTRY, PA
Entity type:Organization
Organization Name:MODRALL DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MODRALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:682-688-7546
Mailing Address - Street 1:2310 HIGHWAY 157 N STE 102
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8845
Mailing Address - Country:US
Mailing Address - Phone:682-688-7546
Mailing Address - Fax:682-688-7546
Practice Address - Street 1:2310 HIGHWAY 157 N STE 102
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8845
Practice Address - Country:US
Practice Address - Phone:682-688-7546
Practice Address - Fax:682-688-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental