Healthcare Provider Details

I. General information

NPI: 1851934236
Provider Name (Legal Business Name): MODERN ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 LAURENCE AVE STE 4
JACKSON MI
49202
US

IV. Provider business mailing address

1030 LAURENCE AVE STE 4
JACKSON MI
49202
US

V. Phone/Fax

Practice location:
  • Phone: 517-888-7338
  • Fax:
Mailing address:
  • Phone: 517-888-7338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SCOTT A. WATTERSON
Title or Position: OWNER/MEMBER
Credential: DDS
Phone: 517-206-1445