Provider Demographics
NPI:1811570492
Name:CLEMSON MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:CLEMSON MODERN DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHRESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:714-845-8890
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:303-952-0892
Practice Address - Street 1:2708 CLEMSON RD STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8033
Practice Address - Country:US
Practice Address - Phone:803-830-5972
Practice Address - Fax:803-440-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty