Provider Demographics
NPI:1679822456
Name:LONDRY & MODLIN DDS PLLC
Entity Type:Organization
Organization Name:LONDRY & MODLIN DDS PLLC
Other - Org Name:LAKESIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-987-9087
Mailing Address - Street 1:19824 W CATAWBA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4046
Mailing Address - Country:US
Mailing Address - Phone:704-987-9087
Mailing Address - Fax:704-987-9044
Practice Address - Street 1:19824 W CATAWBA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4046
Practice Address - Country:US
Practice Address - Phone:704-987-9087
Practice Address - Fax:704-987-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty