Provider Demographics
NPI:1518322023
Name:FONTAINEBLEAU DENTISTRY, PA
Entity Type:Organization
Organization Name:FONTAINEBLEAU DENTISTRY, PA
Other - Org Name:FONTAINEBLEAU DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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:786-418-3074
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:9971 W FLAGLER ST
Practice Address - Street 2:220
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1810
Practice Address - Country:US
Practice Address - Phone:786-418-3074
Practice Address - Fax:786-619-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty