Healthcare Provider Details

I. General information

NPI: 1316700099
Provider Name (Legal Business Name): LONDRY, MODLIN & OBI-GWACHAM DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 WALTERS DIVISION RD STE 2
MONROE NC
28110-8562
US

IV. Provider business mailing address

19810 W CATAWBA AVE # A1
CORNELIUS NC
28031-4056
US

V. Phone/Fax

Practice location:
  • Phone: 704-270-5567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARY CHAFFIN
Title or Position: OWNER
Credential:
Phone: 704-997-8878