Basic Information
| Provider Information | |||||||||
| NPI: | 1396267100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORAL SPRINGS MODERN DENTISTRY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 920050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753920050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5810 WILES RD | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543148343 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCANN | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DDS/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9543148343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.