Provider Demographics
NPI:1578208021
Name:NEWBURGH MODERN DENTISTRY LLC
Entity Type:Organization
Organization Name:NEWBURGH MODERN DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-616-5444
Mailing Address - Street 1:3944 STATE ROAD 261
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3944 STATE ROAD 261
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630
Practice Address - Country:US
Practice Address - Phone:812-616-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-29
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty