MEDICARE: MODLIN & LONDRY VIII DDS PLLC

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	:	1659034411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODLIN & LONDRY VIII DDS PLLC

Provider Business Mailing Address
First Line	:	19810 W CATAWBA AVE # A1
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4056
Country	:	US
Telephone Number	:	704-997-8878
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 PARKWOOD MEDICAL PARK
Second Line	:
City	:	ELKIN
State	:	NC
Zip	:	28621-2444
Country	:	US
Telephone Number	:	336-835-7113
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. LISA KAY TRAVIS
Credential	:
Telephone Number	:	828-850-4316

Provider Enumeration Date	:	10/19/2021
Last Update Date	:	10/19/2021

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