NPIMap

Organization Active NPI

Lake Wylie Modern Dentistry, PC

Doing business as Lake Wylie Modern Dentistry

  • Dentist
  • Lake Wylie, SC
National Provider Identifier
1194376491
Registry record updated Jun 14, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
LAKE WYLIE MODERN DENTISTRY, PC
Doing business as
Lake Wylie Modern Dentistry
Practice address
140 Highway 274
Lake Wylie, SC 29710-6045
Phone
(803) 752-0565
NPI assigned
Sep 27, 2019
Last updated
Jun 14, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 14, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ali Shahrestani, DMD
Title
Owner
Phone
(803) 752-0565

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X Primary

Addresses

Primary practice location

140 Highway 274
Lake Wylie, SC 29710-6045

Mailing address

PO Box 920050
Dallas, TX 75392-0050

Other names 1

  • Lake Wylie Modern Dentistry Doing business as

National Provider Directory

National Provider Directory

Locations

140 Highway 274
Lake Wylie, SC 29710
Phone (803) 752-0565

158 Highway 274
Ste 10A
Lake Wylie, SC 29710

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1569542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655164800000",
    "number": "1194376491",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 920050",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753920050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 HIGHWAY 274",
            "city": "LAKE WYLIE",
            "state": "SC",
            "postal_code": "297106045",
            "telephone_number": "803-752-0565"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE WYLIE MODERN DENTISTRY, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-27",
        "last_updated": "2022-06-14",
        "certification_date": "2022-06-14",
        "status": "A",
        "authorized_official_last_name": "SHAHRESTANI",
        "authorized_official_first_name": "ALI",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "803-752-0565",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Wylie Modern Dentistry",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lake Wylie Modern Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Wylie, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.