Provider Demographics
NPI:1255382800
Name:MODELO DENTAL CARE, INC.
Entity type:Organization
Organization Name:MODELO DENTAL CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAZCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-687-0062
Mailing Address - Street 1:2012 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4131
Mailing Address - Country:US
Mailing Address - Phone:216-687-0062
Mailing Address - Fax:216-687-9529
Practice Address - Street 1:2012 W 25TH ST
Practice Address - Street 2:#720
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-4135
Practice Address - Country:US
Practice Address - Phone:216-687-0062
Practice Address - Fax:216-687-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30193171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0918476Medicaid