Healthcare Provider Details

I. General information

NPI: 1992989412
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS-LEE,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S HIGH ST
ARCANUM OH
45304-1118
US

IV. Provider business mailing address

1 S HIGH ST
ARCANUM OH
45304-1118
US

V. Phone/Fax

Practice location:
  • Phone: 937-692-5150
  • Fax:
Mailing address:
  • Phone: 937-692-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.019758
License Number StateOH

VIII. Authorized Official

Name: RHONDA KELLER
Title or Position: DISTRICT MANAGER
Credential:
Phone: 937-278-7956