Provider Demographics
NPI:1669207957
Name:MODERN DENTAL SPECIALIST, LLC
Entity type:Organization
Organization Name:MODERN DENTAL SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANTEB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-631-3368
Mailing Address - Street 1:4618 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2956
Mailing Address - Country:US
Mailing Address - Phone:702-200-9000
Mailing Address - Fax:
Practice Address - Street 1:4416 E BONANZA RD UNIT 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-6349
Practice Address - Country:US
Practice Address - Phone:702-200-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL SPECIALISTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty