=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629615497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINTER HAVEN MODERN DENTISTRY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2019
-----------------------------------------------------
Last Update Date | 11/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 565 CYPRESS GARDENS BLVD
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-656-4777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17000 RED HILL AVE
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92614-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/GP
-----------------------------------------------------
Name | DR. KATIE L MCCANN LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 863-656-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------