Basic Information
Provider Information | |||||||||
NPI: | 1518428374 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPRINGDALE MODERN DENTISTRY, PC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPRINGDALE MODERN DENTISTRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 920050 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753920050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458890 | ||||||||
FaxNumber: | 3039520892 | ||||||||
Practice Location | |||||||||
Address1: | 403 E KEMPER RD | ||||||||
Address2: |   | ||||||||
City: | SPRINGDALE | ||||||||
State: | OH | ||||||||
PostalCode: | 452463228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137297245 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2019 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NGUYEN | ||||||||
AuthorizedOfficialFirstName: | BACH | ||||||||
AuthorizedOfficialMiddleName: | X | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DDS | ||||||||
AuthorizedOfficialTelephone: | 5137297245 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.