Provider Demographics
NPI:1477647089
Name:MODELEVSKY, STEPHEN ALLEN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ALLEN
Last Name:MODELEVSKY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1920
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403
Mailing Address - Country:US
Mailing Address - Phone:870-972-8570
Mailing Address - Fax:870-972-5451
Practice Address - Street 1:906 OSLER DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-8570
Practice Address - Fax:870-972-5451
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR23021223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART20486Medicare UPIN
AR58877Medicare ID - Type Unspecified