MEDICARE: CRAIG S. MODZELEWSKI DMD INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3892	SC

General Provider Information

NPI Number	:	1114163524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRAIG S. MODZELEWSKI DMD INC.

Provider Business Mailing Address
First Line	:	522 MAIN ST N
Second Line	:
City	:	ALLENDALE
State	:	SC
Zip	:	29810-3720
Country	:	US
Telephone Number	:	803-584-2105
Fax Number	:	803-584-5757

Provider Business Practice Location Address
First Line	:	522 MAIN ST N
Second Line	:
City	:	ALLENDALE
State	:	SC
Zip	:	29810-3720
Country	:	US
Telephone Number	:	803-584-2105
Fax Number	:	803-584-5757

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CRAIG STEVEN MODZELEWSKI
Credential	:	DMD
Telephone Number	:	803-584-2105

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/07/2009

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