Provider Demographics
NPI:1437785847
Name:MODERN DENTAL CAPE CORAL PLLC
Entity Type:Organization
Organization Name:MODERN DENTAL CAPE CORAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACKENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-736-7924
Mailing Address - Street 1:14575 TAMIAMI TRL STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2743
Mailing Address - Country:US
Mailing Address - Phone:941-888-2362
Mailing Address - Fax:
Practice Address - Street 1:706 SW PINE ISLAND RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991
Practice Address - Country:US
Practice Address - Phone:941-610-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty