Provider Demographics
NPI:1326118340
Name:MODERN DENTAL INNOVATIONS, P C
Entity Type:Organization
Organization Name:MODERN DENTAL INNOVATIONS, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:T
Authorized Official - Last Name:ATHANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-498-3333
Mailing Address - Street 1:1707 SHERMER ROAD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5375
Mailing Address - Country:US
Mailing Address - Phone:847-498-3333
Mailing Address - Fax:847-498-3339
Practice Address - Street 1:1707 SHERMER ROAD
Practice Address - Street 2:SUITE 125
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:847-498-3333
Practice Address - Fax:847-498-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty