MEDICARE: MODERN DENTAL CARE

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1376125518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL CARE

Provider Business Mailing Address
First Line	:	3420 FILBERT HWY
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-5602
Country	:	US
Telephone Number	:	803-286-6455
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 FILBERT HWY
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-5602
Country	:	US
Telephone Number	:	803-286-6455
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATION
Name	:	IRINA FRIDMAN
Credential	:
Telephone Number	:	803-286-6455

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	04/27/2021

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Directions to “MODERN DENTAL CARE ” Practice Location

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