MEDICARE: REGENCY 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1477446078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENCY MODERN DENTISTRY, PA

Provider Business Mailing Address
First Line	:	PO BOX 660041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0041
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9406 ATLANTIC BLVD STE 1
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-8221
Country	:	US
Telephone Number	:	904-204-9105
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MINH PHAM
Credential	:
Telephone Number	:	714-845-8500

Provider Enumeration Date	:	06/02/2025
Last Update Date	:	06/02/2025

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