Provider Demographics
NPI:1114163524
Name:CRAIG S. MODZELEWSKI DMD INC.
Entity Type:Organization
Organization Name:CRAIG S. MODZELEWSKI DMD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:MODZELEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-584-2105
Mailing Address - Street 1:522 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:SC
Mailing Address - Zip Code:29810-3720
Mailing Address - Country:US
Mailing Address - Phone:803-584-2105
Mailing Address - Fax:803-584-5757
Practice Address - Street 1:522 MAIN ST N
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:SC
Practice Address - Zip Code:29810-3720
Practice Address - Country:US
Practice Address - Phone:803-584-2105
Practice Address - Fax:803-584-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty