Provider Demographics
NPI:1992032486
Name:MODERN LEGACY, INC.
Entity type:Organization
Organization Name:MODERN LEGACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JACHELLE
Authorized Official - Middle Name:AG
Authorized Official - Last Name:SPRATTLING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-810-4259
Mailing Address - Street 1:203 S MARION ST
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-1522
Mailing Address - Country:US
Mailing Address - Phone:843-752-7655
Mailing Address - Fax:843-752-4500
Practice Address - Street 1:203 S MARION ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1522
Practice Address - Country:US
Practice Address - Phone:843-752-7655
Practice Address - Fax:843-752-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty