Provider Demographics
NPI:1922428879
Name:MODERN PERIODONTICS, PA
Entity Type:Organization
Organization Name:MODERN PERIODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUZNIA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:904-278-1175
Mailing Address - Street 1:1409 KINGSLEY AVE
Mailing Address - Street 2:SUITE 9A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4537
Mailing Address - Country:US
Mailing Address - Phone:904-278-1175
Mailing Address - Fax:
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 9A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-278-1175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15267122300000X
FLDN17936122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty