Provider Demographics
NPI:1275289472
Name:MODERN DENTAL CENTER STEVENS POINT LLC
Entity Type:Organization
Organization Name:MODERN DENTAL CENTER STEVENS POINT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-424-2990
Mailing Address - Street 1:5541 US HIGHWAY 10 E
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-8306
Mailing Address - Country:US
Mailing Address - Phone:715-344-7911
Mailing Address - Fax:
Practice Address - Street 1:5541 US HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8306
Practice Address - Country:US
Practice Address - Phone:715-344-7911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty