Provider Demographics
NPI:1285371187
Name:MT JULIET MODERN DENTISTRY PC
Entity type:Organization
Organization Name:MT JULIET MODERN DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-716-1653
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:600 S MOUNT JULIET RD STE 3
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6497
Practice Address - Country:US
Practice Address - Phone:615-716-1653
Practice Address - Fax:615-866-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-13
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty