Provider Demographics
NPI:1164510129
Name:MODERN AMERICAN DENTAL CLINIC PC
Entity Type:Organization
Organization Name:MODERN AMERICAN DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST DDS
Authorized Official - Phone:313-582-1919
Mailing Address - Street 1:14350 W WARREN
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-582-1919
Mailing Address - Fax:313-582-0300
Practice Address - Street 1:14350 W WARREN
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-582-1919
Practice Address - Fax:313-582-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4773148Medicaid
MID15159MIOtherLICENSE