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General NPI Number Information
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NPI Number | 1437785847
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL CAPE CORAL PLLC
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Dates
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Enumeration Date | 03/17/2020
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Last Update Date | 03/17/2020
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Provider Practice Location Address
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Address Line | 706 SW PINE ISLAND RD SUITE 103
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City | CAPE CORAL
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State | FL
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Zip | 33991
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Country | US
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Telephone | 941-610-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 14575 TAMIAMI TRL STE A
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City | NORTH PORT
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State | FL
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Zip | 34287-2743
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Country | US
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Telephone | 941-888-2362
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Fax |
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Authorized Official
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Title or Position | PERIODONTIST
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Name | TYLER M BLACKENBURG
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Credential | DMD
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Telephone | 954-736-7924
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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