Basic Information
Provider Information | |||||||||
NPI: | 1891262234 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEXINGTON MODERN DENTISTRY, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LEXINGTON 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: | 7148458500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 808 HIGHWAY 378 STE C | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | SC | ||||||||
PostalCode: | 290728379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8033391021 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2018 | ||||||||
LastUpdateDate: | 02/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHAHRESTANI | ||||||||
AuthorizedOfficialFirstName: | ALI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DDS | ||||||||
AuthorizedOfficialTelephone: | 8033391021 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 02/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.