Provider Demographics
NPI:1871651992
Name:MODERN DENTAL PROFESSIONALS PHILADELPHA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS PHILADELPHA PC
Other - Org Name:PRO-DENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-459-0845
Mailing Address - Street 1:1440 CONCHESTER HWY
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-2124
Mailing Address - Country:US
Mailing Address - Phone:610-459-0845
Mailing Address - Fax:
Practice Address - Street 1:1440 CONCHESTER HWY
Practice Address - Street 2:
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061-2124
Practice Address - Country:US
Practice Address - Phone:610-459-0845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA22D1021383001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty