Provider Demographics
NPI:1902535396
Name:LONDRY & MODLIN X DDS PLLC
Entity Type:Organization
Organization Name:LONDRY & MODLIN X DDS PLLC
Other - Org Name:STATESVILLE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-997-8878
Mailing Address - Street 1:19810 W CATAWBA AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4056
Mailing Address - Country:US
Mailing Address - Phone:704-997-8878
Mailing Address - Fax:704-997-8511
Practice Address - Street 1:1207 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3511
Practice Address - Country:US
Practice Address - Phone:704-873-4271
Practice Address - Fax:704-873-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-09
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty