NPIMap

Organization Active NPI

St. Charles Modern Dental, LLC

  • General Practice Dentistry
  • St Charles, IL
National Provider Identifier
1912220773
Registry record updated Mar 9, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
019027170 Issued in IL
Legal business name
ST. CHARLES MODERN DENTAL, LLC
Practice address
855 S Randall Rd
St Charles, IL 60174-1570
Phone
(630) 587-2700
Fax
(630) 405-1738
NPI assigned
Mar 9, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kianor Shahmohmmadi, DMD
Title
Ceo - Nexus Dentistry
Phone
(618) 917-5808

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X 019027170 IL Primary

Addresses

Primary practice location

855 S Randall Rd
St Charles, IL 60174-1570

Mailing address

855 S Randall Rd
St Charles, IL 60174-1570
Phone (630) 587-2700

Other names 1

  • St. Charles Modern Dental Other name

National Provider Directory

National Provider Directory
Tax ID family
St Charles Modern Dental2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1268092800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1268092800000",
    "number": "1912220773",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "855 S RANDALL RD",
            "city": "ST CHARLES",
            "state": "IL",
            "postal_code": "601741570",
            "telephone_number": "630-587-2700",
            "fax_number": "630-405-1738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "855 S RANDALL RD",
            "city": "ST CHARLES",
            "state": "IL",
            "postal_code": "601741570",
            "telephone_number": "630-587-2700",
            "fax_number": "630-405-1738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. CHARLES MODERN DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-03-09",
        "last_updated": "2010-03-09",
        "status": "A",
        "authorized_official_last_name": "SHAHMOHMMADI",
        "authorized_official_first_name": "KIANOR",
        "authorized_official_title_or_position": "CEO - NEXUS DENTISTRY",
        "authorized_official_telephone_number": "618-917-5808",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019027170",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Charles Modern Dental",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in St Charles, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.