MEDICARE: MODERN DENTAL

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

General Provider Information

NPI Number	:	1114586161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL

Provider Business Mailing Address
First Line	:	3604 WEST LOOP UNIT A2
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8029
Country	:	US
Telephone Number	:	979-320-8000
Fax Number	:	832-437-8754

Provider Business Practice Location Address
First Line	:	3604 WEST LOOP UNIT A2
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8029
Country	:	US
Telephone Number	:	979-320-8000
Fax Number	:	832-437-8754

Authorized Official
Title or Position	:	OWNER
Name	:	GAGANDEEP KAHLON
Credential	:	DDS
Telephone Number	:	979-320-8000

Provider Enumeration Date	:	06/12/2019
Last Update Date	:	06/12/2019

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Directions to “MODERN DENTAL ” Practice Location

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