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General NPI Number Information
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NPI Number | 1427747880
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Entity Type | Organization
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Legal Business Name | MODERN FAMILY DENTISTRY
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Dates
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Enumeration Date | 05/02/2023
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Last Update Date | 05/02/2023
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Provider Practice Location Address
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Address Line | 1815 SE US HIGHWAY 19
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-9065
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Country | US
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Telephone | 352-795-1223
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Fax | 352-453-5547
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Provider Business Mailing Address
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Address Line | 1815 SE US HIGHWAY 19
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City | CRYSTAL RIVER
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State | FL
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Zip | 34429-9065
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Country | US
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Telephone | 352-795-1223
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Fax | 352-453-5547
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL S MASTERSON
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Credential | DMD
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Telephone | 352-795-1223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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