MEDICARE: MODELO DENTAL CENTER 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

General Provider Information

NPI Number	:	1154529295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODELO DENTAL CENTER INC.

Provider Business Mailing Address
First Line	:	2012 W 25TH ST STE 720
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-4131
Country	:	US
Telephone Number	:	216-687-0062
Fax Number	:	216-687-9529

Provider Business Practice Location Address
First Line	:	2012 W 25TH ST STE 720
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-4131
Country	:	US
Telephone Number	:	216-687-0062
Fax Number	:	216-687-9529

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SARA NAZCO
Credential	:	D.D. S.
Telephone Number	:	216-687-0062

Provider Enumeration Date	:	07/10/2007
Last Update Date	:	07/10/2007

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