Provider Demographics
NPI:1821413733
Name:MODERN ORTHODONTICS PC
Entity Type:Organization
Organization Name:MODERN ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-993-5454
Mailing Address - Street 1:391 E 149TH ST RM 214
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3922
Mailing Address - Country:US
Mailing Address - Phone:718-993-5454
Mailing Address - Fax:
Practice Address - Street 1:391 E 149TH ST RM 214
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3922
Practice Address - Country:US
Practice Address - Phone:718-993-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223X0400X
NY50 056630261QD0000X
NJ22DI02562100261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental