Provider Demographics
NPI:1689427767
Name:LONDRY, MODLIN, TUCKER IV DDS PLLC
Entity Type:Organization
Organization Name:LONDRY, MODLIN, TUCKER IV DDS PLLC
Other - Org Name:CAROLINA KIDS DENTISTRY- WAXHAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-799-8878
Mailing Address - Street 1:20311 CHARTWELL CENTER DR.
Mailing Address - Street 2:PO BOX #2127
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9817 SUZANNE CT STE B
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6976
Practice Address - Country:US
Practice Address - Phone:704-997-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty