MEDICARE: MODERN DENTISTRY AND COSMETOLOGY CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QD0000X	Dental Clinic/Center
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1386270841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTISTRY AND COSMETOLOGY CENTER

Provider Business Mailing Address
First Line	:	11911 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2541
Country	:	US
Telephone Number	:	215-673-9050
Fax Number	:

Provider Business Practice Location Address
First Line	:	11911 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-2541
Country	:	US
Telephone Number	:	215-673-9050
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IRINA STEPANSKY
Credential	:	DMD
Telephone Number	:	215-676-9050

Provider Enumeration Date	:	03/17/2020
Last Update Date	:	03/17/2020

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