Provider Demographics
NPI:1427418748
Name:MIAMI SHORES MODERN DENTISTRY, PA
Entity Type:Organization
Organization Name:MIAMI SHORES MODERN DENTISTRY, PA
Other - Org Name:MIAMI SHORES MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MINH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-310-4816
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:9503 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2704
Practice Address - Country:US
Practice Address - Phone:786-310-4816
Practice Address - Fax:786-623-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty