Provider Demographics
NPI:1265309496
Name:MODERN DENTAL LLC
Entity type:Organization
Organization Name:MODERN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ-FREED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-261-4697
Mailing Address - Street 1:8604 S QUIET OAK CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-4138
Mailing Address - Country:US
Mailing Address - Phone:605-261-4697
Mailing Address - Fax:
Practice Address - Street 1:5912 E 18 STREET
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110
Practice Address - Country:US
Practice Address - Phone:605-261-4697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1275784605Medicaid
SD1710141726Medicaid