Provider Demographics
NPI:1790502946
Name:MODLIN & LONDRY XIV LLC
Entity type:Organization
Organization Name:MODLIN & LONDRY XIV LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTAILING
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-997-8878
Mailing Address - Street 1:PO BOX 2127
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-2127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:882 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2126
Practice Address - Country:US
Practice Address - Phone:704-997-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty