Provider Demographics
NPI:1265889166
Name:MODERN DENTAL PROFESSIONALS UT, PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS UT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:493-089-7929
Mailing Address - Street 1:8415 DATAPOINT DRIVE
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:714-578-6358
Mailing Address - Fax:
Practice Address - Street 1:5974 S. FASHION POINTE DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-475-6121
Practice Address - Fax:801-471-0919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESSIONALS UT, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-20
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141895-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty