| Organization Name: | MODERN ART OF DENTISTRY, INC |
| NPI Number: | 1003142100 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KARINA LYON GAVRILOV (OWNER) |
| Mailing Address: | 75 S Milwaukee Ave Wheeling |
| State: | IL US |
| Postal Code: | 600903187 |
| Phone Number: | 8474650800 |
| Fax Number: | 8474650053 |
| NPI Enumeration Date: | 10/23/2009 |
| NPI Last Update Date: | 10/23/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 0019-024691 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |