Provider Demographics
NPI:1912220773
Name:ST. CHARLES MODERN DENTAL, LLC
Entity Type:Organization
Organization Name:ST. CHARLES MODERN DENTAL, LLC
Other - Org Name:ST. CHARLES MODERN DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO - NEXUS DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:KIANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHMOHMMADI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-917-5808
Mailing Address - Street 1:855 S RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1570
Mailing Address - Country:US
Mailing Address - Phone:630-587-2700
Mailing Address - Fax:630-405-1738
Practice Address - Street 1:855 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1570
Practice Address - Country:US
Practice Address - Phone:630-587-2700
Practice Address - Fax:630-405-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190271701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty