NPIMap

Organization Active NPI

Lakeland Modern Dentistry, PA

Doing business as Lakeland Modern Dentistry

  • Dentist
  • Lakeland, FL
National Provider Identifier
1235649518
Registry record updated Jun 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
LAKELAND MODERN DENTISTRY, PA
Doing business as
Lakeland Modern Dentistry
Practice address
4620 S Florida Ave Ste 120
Lakeland, FL 33813-2166
Phone
(863) 216-5765
NPI assigned
Oct 2, 2017
Last updated
Jun 15, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 15, 2022

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

Authorized official

Name
Dr. Mary Mabry, DDSNPI 1386262301
Title
Owner Doctor
Phone
(863) 216-5765

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X NU Primary

Addresses

Primary practice location

4620 S Florida Ave Ste 120
Lakeland, FL 33813-2166

Mailing address

PO Box 920050
Dallas, TX 75392-0050
Phone (714) 845-8890

Other names 1

  • Lakeland Modern Dentistry Doing business as

National Provider Directory

National Provider Directory

Locations

4620 S Florida Ave
Ste 120
Lakeland, FL 33813
Phone (863) 216-5765

Practitioners & affiliated clinicians

Practitioners 9

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": "1506902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655251200000",
    "number": "1235649518",
    "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",
            "telephone_number": "714-845-8890",
            "fax_number": "303-952-0892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4620 S FLORIDA AVE STE 120",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338132166",
            "telephone_number": "863-216-5765"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKELAND MODERN DENTISTRY, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-10-02",
        "last_updated": "2022-06-15",
        "certification_date": "2022-06-15",
        "status": "A",
        "authorized_official_last_name": "MABRY",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "OWNER DOCTOR",
        "authorized_official_telephone_number": "863-216-5765",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeland Modern Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lakeland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 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.