MEDICARE: MODELO DENTAL CARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3019317	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255382800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODELO DENTAL CARE, INC.

Provider Business Mailing Address
First Line	:	2012 W 25TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-4131
Country	:	US
Telephone Number	:	216-687-0062
Fax Number	:	216-687-9529

Provider Business Practice Location Address
First Line	:	2012 W 25TH ST
Second Line	:	#720
City	:	CLEVELAND
State	:	OH
Zip	:	44113-4135
Country	:	US
Telephone Number	:	216-687-0062
Fax Number	:	216-687-9529

Authorized Official
Title or Position	:	DDS
Name	:	SARA NAZCO
Credential	:
Telephone Number	:	216-687-0062

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	10/20/2008

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Directions to “MODELO DENTAL CARE, INC. ” Practice Location

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