Port Orange Modern Dentistry, PA
Dentist in Port Orange, FL. Organization (NPI-2).
NPI number1982179818
StatusActive
Last updated in NPPESAug 25, 2022
Details
- NPI
- 1982179818
- Entity type
- Organization (NPI-2)
- Legal business name
- Port Orange Modern Dentistry, PA
- Organization subpart
- No
- Enumeration date
- Oct 8, 2018
- Certification date
- Aug 25, 2022
- Last updated
- Aug 25, 2022
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 122300000X | Dentist | – | – | Yes |
Other names
- Port Orange Modern Dentistry (Doing Business As)
Practice location
1765 Dunlawton Ave.Suite 103
Port Orange, FL 32129
Phone 386-259-3905 · Fax 386-259-3905
Mailing address
Po Box 920050Dallas, TX 75392-0050
Phone 714-845-8890 · Fax 303-952-0892
Authorized official
Minh B Pham
Owner/Gp
3862593905
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