MEDICARE: MODERN DENTAL PROFESSIONALS AZ, PC

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

General Provider Information

NPI Number	:	1376814012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS AZ, PC

Provider Business Mailing Address
First Line	:	8415 DATAPOINT DR STE 1020
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3277
Country	:	US
Telephone Number	:	480-857-8270
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 S ARIZONA AVE STE 1
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85286-6509
Country	:	US
Telephone Number	:	480-857-8270
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAVAN NARLA
Credential	:
Telephone Number	:	520-670-3758

Provider Enumeration Date	:	01/25/2012
Last Update Date	:	12/18/2025

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