Basic Information
| Provider Information | |||||||||
| NPI: | 1902356389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTON MODERN DENTISTRY, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTON MODERN DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458500 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 INDIAN TRACE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542482895 | ||||||||
| FaxNumber: | 9542482896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCANN | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9542482895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.