Basic Information
| Provider Information | |||||||||
| NPI: | 1174071500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLERMONT SMILES DENTISTRY, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLERMONT SMILES DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 HOOKS STREET | ||||||||
| Address2: | 100 | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523607274 | ||||||||
| FaxNumber: | 3528774379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCANN | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 3523607274 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.