Provider Demographics
NPI:1013593953
Name:MODERN DENTAL OF SPRINGFIELD PLLC
Entity Type:Organization
Organization Name:MODERN DENTAL OF SPRINGFIELD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-698-3400
Mailing Address - Street 1:3240 HEDLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6360
Mailing Address - Country:US
Mailing Address - Phone:217-698-3400
Mailing Address - Fax:217-698-3410
Practice Address - Street 1:3240 HEDLEY RD STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6360
Practice Address - Country:US
Practice Address - Phone:217-698-3400
Practice Address - Fax:217-698-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1083793939OtherDENTIST
IL1528441557OtherDENTIST