Healthcare Provider Details

I. General information

NPI: 1437785847
Provider Name (Legal Business Name): MODERN DENTAL CAPE CORAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 SW PINE ISLAND RD SUITE 103
CAPE CORAL FL
33991
US

IV. Provider business mailing address

14575 TAMIAMI TRL STE A
NORTH PORT FL
34287-2743
US

V. Phone/Fax

Practice location:
  • Phone: 941-610-6200
  • Fax:
Mailing address:
  • Phone: 941-888-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: TYLER M BLACKENBURG
Title or Position: PERIODONTIST
Credential: DMD
Phone: 954-736-7924