Provider Demographics
NPI:1982179818
Name:PORT ORANGE MODERN DENTISTRY, PA
Entity Type:Organization
Organization Name:PORT ORANGE MODERN DENTISTRY, PA
Other - Org Name:PORT ORANGE MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/GP
Authorized Official - Prefix:DR
Authorized Official - First Name:MINH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:386-259-3905
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:303-952-0892
Practice Address - Street 1:1765 DUNLAWTON AVE.
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-259-3905
Practice Address - Fax:386-259-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty