Provider Demographics
NPI:1568789709
Name:MODERN DENTAL CARE PC
Entity Type:Organization
Organization Name:MODERN DENTAL CARE PC
Other - Org Name:SMILES MODERN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-540-1886
Mailing Address - Street 1:1750 N STONEBRIDGE DR
Mailing Address - Street 2:#105
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-7551
Mailing Address - Country:US
Mailing Address - Phone:972-540-1886
Mailing Address - Fax:972-540-0770
Practice Address - Street 1:1750 N STONEBRIDGE DR
Practice Address - Street 2:#105
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-7551
Practice Address - Country:US
Practice Address - Phone:972-540-1886
Practice Address - Fax:972-540-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25069261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental