Provider Demographics
NPI:1427309707
Name:MODERN DENTAL LLC
Entity type:Organization
Organization Name:MODERN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-839-2372
Mailing Address - Street 1:600 22ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0986
Mailing Address - Country:US
Mailing Address - Phone:701-839-2372
Mailing Address - Fax:
Practice Address - Street 1:600 22ND AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0986
Practice Address - Country:US
Practice Address - Phone:701-839-2372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2128261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental