Provider Demographics
NPI:1871766386
Name:MODERN DENTAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:MODERN DENTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORDER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-965-9531
Mailing Address - Street 1:28 E BROADWAY
Mailing Address - Street 2:3F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-6803
Mailing Address - Country:US
Mailing Address - Phone:212-965-9531
Mailing Address - Fax:212-965-9124
Practice Address - Street 1:28 E BROADWAY
Practice Address - Street 2:3F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-6803
Practice Address - Country:US
Practice Address - Phone:212-965-9531
Practice Address - Fax:212-965-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046408122300000X
NY0460341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty