Provider Demographics
NPI:1922267657
Name:MODELEVSKY DDS PA
Entity Type:Organization
Organization Name:MODELEVSKY DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:MODELEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:870-972-8570
Mailing Address - Street 1:PO BOX 1920
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1920
Mailing Address - Country:US
Mailing Address - Phone:870-972-8570
Mailing Address - Fax:870-972-5451
Practice Address - Street 1:906 OSLER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4366
Practice Address - Country:US
Practice Address - Phone:870-972-8570
Practice Address - Fax:870-972-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2302261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery