MEDICARE: MODERN DENTAL INCORPORATED

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	25146	TX

General Provider Information

NPI Number	:	1114220647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL INCORPORATED

Provider Business Mailing Address
First Line	:	1821 N ZARAGOSA
Second Line	:	SUITE 207-316
City	:	EL PASO
State	:	TX
Zip	:	79936-7912
Country	:	US
Telephone Number	:	866-371-5205
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 N ZARAGOSA
Second Line	:	SUITE 207-316
City	:	EL PASO
State	:	TX
Zip	:	79936-7912
Country	:	US
Telephone Number	:	866-371-5205
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARSHA AMANDA
Credential	:	D.M.D
Telephone Number	:	866-371-5205

Provider Enumeration Date	:	12/05/2010
Last Update Date	:	02/03/2011

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