Provider Demographics
NPI:1568978476
Name:MODERN ORTHODONTICS LLC
Entity Type:Organization
Organization Name:MODERN ORTHODONTICS LLC
Other - Org Name:SOUTHINGTON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANUJ
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMANOCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-406-4322
Mailing Address - Street 1:233 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2261
Mailing Address - Country:US
Mailing Address - Phone:603-969-4322
Mailing Address - Fax:
Practice Address - Street 1:1095 WEST ST STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1023
Practice Address - Country:US
Practice Address - Phone:860-406-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty