Healthcare Provider Details

I. General information

NPI: 1932845641
Provider Name (Legal Business Name): CANTON MODERN DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 WASHINGTON ST STE 222
CANTON MA
02021-4009
US

IV. Provider business mailing address

PO BOX 920050
DALLAS TX
75392-0050
US

V. Phone/Fax

Practice location:
  • Phone: 781-451-3150
  • Fax: 781-451-3240
Mailing address:
  • Phone: 714-845-8890
  • 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 Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID Y. LEE
Title or Position: OWNER DOCTOR
Credential: DDS
Phone: 781-451-3150