Provider Demographics
NPI:1548330210
Name:MODERN DENTAL PROFESSIONALS-EL PASO, PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS-EL PASO, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-833-1800
Mailing Address - Street 1:6501 WINDCREST DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3087
Mailing Address - Country:US
Mailing Address - Phone:972-212-8200
Mailing Address - Fax:972-767-4326
Practice Address - Street 1:7040 N MESA ST
Practice Address - Street 2:SUITE A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3669
Practice Address - Country:US
Practice Address - Phone:915-833-1800
Practice Address - Fax:915-833-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty