MEDICARE: MEMORIAL MODERN DENTISTRY,PC

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	:	1972052629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL MODERN DENTISTRY,PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	9355 KATY FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-1516
Country	:	US
Telephone Number	:	713-300-7999
Fax Number	:	713-277-7307

Authorized Official
Title or Position	:	ADMIN
Name	:	DR. JOHN S BARNES
Credential	:	DDS
Telephone Number	:	713-300-7999

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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Directions to “MEMORIAL MODERN DENTISTRY,PC ” Practice Location

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