Provider Demographics
NPI:1407541337
Name:MODERN DENTAL SPECIALIST, LLC
Entity Type:Organization
Organization Name:MODERN DENTAL SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANTEB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-631-3368
Mailing Address - Street 1:4618 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2956
Mailing Address - Country:US
Mailing Address - Phone:702-623-3200
Mailing Address - Fax:
Practice Address - Street 1:4610 E SUNSET RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2202
Practice Address - Country:US
Practice Address - Phone:702-200-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty