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General NPI Number Information
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NPI Number | 1255382800
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Entity Type | Organization
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Legal Business Name | MODELO DENTAL CARE, INC.
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 10/20/2008
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Provider Practice Location Address
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Address Line | 2012 W 25TH ST #720
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City | CLEVELAND
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State | OH
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Zip | 44113-4135
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Country | US
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Telephone | 216-687-0062
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Fax | 216-687-9529
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Provider Business Mailing Address
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Address Line | 2012 W 25TH ST
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City | CLEVELAND
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State | OH
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Zip | 44113-4131
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Country | US
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Telephone | 216-687-0062
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Fax | 216-687-9529
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Authorized Official
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Title or Position | DDS
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Name | SARA NAZCO
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Credential |
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Telephone | 216-687-0062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3019317
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License Number State | OH
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