Provider Demographics
NPI:1851934236
Name:MODERN ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:MODERN ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-206-1445
Mailing Address - Street 1:1030 LAURENCE AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202
Mailing Address - Country:US
Mailing Address - Phone:517-888-7338
Mailing Address - Fax:
Practice Address - Street 1:1030 LAURENCE AVE
Practice Address - Street 2:STE 4
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202
Practice Address - Country:US
Practice Address - Phone:517-888-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty