Provider Demographics
NPI:1164606687
Name:MODERN DENTAL PROFESSIONALS-LEE,INC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS-LEE,INC
Other - Org Name:MONARCH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-278-7956
Mailing Address - Street 1:5561 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1451
Mailing Address - Country:US
Mailing Address - Phone:937-854-1836
Mailing Address - Fax:
Practice Address - Street 1:5561 SALEM AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1451
Practice Address - Country:US
Practice Address - Phone:937-854-1836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESSIONALS-LEE,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0197581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2181446Medicaid