Provider Demographics
NPI:1871006742
Name:DENTISTS OF MELBOURNE, PA
Entity Type:Organization
Organization Name:DENTISTS OF MELBOURNE, PA
Other - Org Name:DENTISTS OF MELBOURNE
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 LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-420-4142
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:
Mailing Address - Fax:
Practice Address - Street 1:6455 N WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2020
Practice Address - Country:US
Practice Address - Phone:321-420-4142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty