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General NPI Number Information
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NPI Number | 1821155128
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL PROFESSIONALS - INDIANA, PC
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 09/02/2016
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Provider Practice Location Address
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Address Line | 304 NORRIS AVE
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City | NORTH VERNON
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State | IN
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Zip | 47265-2343
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Country | US
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Telephone | 812-346-8000
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Fax | 812-346-3990
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Provider Business Mailing Address
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Address Line | 8415 DATAPOINT DR STE. 1020
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City | SAN ANTONIO
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State | TX
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Zip | 78229-3298
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Country | US
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Telephone | 714-578-6358
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JESSICA J SINCLAIR
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Credential | DDS
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Telephone | 714-578-6358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12010661A
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License Number State | IN
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