MEDICARE: BOYNTON BEACH MODERN DENTISTRY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1194288985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYNTON BEACH MODERN DENTISTRY, PA

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7375 BOYNTON BEACH BLVD, BLDG D
Second Line	:	SUITE 445
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437
Country	:	US
Telephone Number	:	561-200-2904
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DDS
Name	:	DR. MINH PHAM
Credential	:	DDS
Telephone Number	:	561-200-2904

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	07/10/2024

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