Provider Demographics
NPI:1700650371
Name:LONDRY, MODLIN, TUCKER II DDS PLLC
Entity Type:Organization
Organization Name:LONDRY, MODLIN, TUCKER II DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JALONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-997-8878
Mailing Address - Street 1:19810 W CATAWBA AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4056
Mailing Address - Country:US
Mailing Address - Phone:704-997-8878
Mailing Address - Fax:
Practice Address - Street 1:705 COLISEUM DR NW
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5312
Practice Address - Country:US
Practice Address - Phone:336-721-7921
Practice Address - Fax:336-721-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty