MEDICARE: LAKE WYLIE MODERN DENTISTRY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1194376491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WYLIE MODERN DENTISTRY, PC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 HIGHWAY 274
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-6045
Country	:	US
Telephone Number	:	803-752-0565
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALI SHAHRESTANI
Credential	:	DMD
Telephone Number	:	803-752-0565

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	06/14/2022

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