Provider Demographics
NPI:1659815306
Name:MOUNT DORA MODERN DENTISTRY, PA
Entity Type:Organization
Organization Name:MOUNT DORA MODERN DENTISTRY, PA
Other - Org Name:MOUNT DORA MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-270-3015
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:714-845-8500
Mailing Address - Fax:
Practice Address - Street 1:17365 US HWY 441
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-270-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty