Healthcare Provider Details

I. General information

NPI: 1952366973
Provider Name (Legal Business Name): MODERN ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 E 149TH ST RM 214
BRONX NY
10455-3922
US

IV. Provider business mailing address

391 E 149TH ST RM 214
BRONX NY
10455-3922
US

V. Phone/Fax

Practice location:
  • Phone: 718-993-5454
  • Fax: 718-993-5455
Mailing address:
  • Phone: 718-993-5454
  • Fax: 718-993-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0469571
License Number StateNY

VIII. Authorized Official

Name: DR. KENNETH BRUCE COOPERMAN
Title or Position: OWNER
Credential: DMD
Phone: 718-993-5454