Provider Demographics
NPI:1437519998
Name:DAVIE MODERN DENTISTRY, PA
Entity Type:Organization
Organization Name:DAVIE MODERN DENTISTRY, PA
Other - Org Name:DAVIE MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-248-2742
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 1:5796 S UNIVERSITY DR
Practice Address - Street 2:102
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328
Practice Address - Country:US
Practice Address - Phone:954-248-2742
Practice Address - Fax:954-251-4141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty