Healthcare Provider Details

I. General information

NPI: 1134654064
Provider Name (Legal Business Name): WEST PINES MODERN DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18312 PINES BLVD
PEMBROKE PINES FL
33029-1412
US

IV. Provider business mailing address

17000 RED HILL AVE
IRVINE CA
92614-5626
US

V. Phone/Fax

Practice location:
  • Phone: 786-204-0713
  • Fax: 786-204-0714
Mailing address:
  • Phone: 714-845-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: KATIE MCCANN
Title or Position: OWNER
Credential:
Phone: 786-204-0713