Provider Demographics
NPI:1386828812
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 1:1475 UPPER VALLEY PIKE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-4047
Mailing Address - Country:US
Mailing Address - Phone:937-322-7549
Mailing Address - Fax:
Practice Address - Street 1:1475 UPPER VALLEY PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-4047
Practice Address - Country:US
Practice Address - Phone:937-322-7549
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
OH2181419Medicaid