Provider Demographics
NPI:1780998443
Name:MODERN DENTAL
Entity type:Organization
Organization Name:MODERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-578-6633
Mailing Address - Street 1:3610 SHIRE BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2241
Mailing Address - Country:US
Mailing Address - Phone:972-578-6633
Mailing Address - Fax:
Practice Address - Street 1:3610 SHIRE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2241
Practice Address - Country:US
Practice Address - Phone:972-578-6633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22246261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental