Provider Demographics
NPI:1497064851
Name:LAVEEN MODERN DENTISTRY, LLP
Entity Type:Organization
Organization Name:LAVEEN MODERN DENTISTRY, LLP
Other - Org Name:LAVEEN MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DMD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-237-0613
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 1:5045 W BASELINE RD STE 135
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-7394
Practice Address - Country:US
Practice Address - Phone:602-237-0613
Practice Address - Fax:602-237-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty