Modern Dental Cape Coral PLLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

MODERN DENTAL CAPE CORAL PLLC

Practice address

706 SW Pine Island Rd
Suite 103
Cape Coral, FL 33991

Phone

(941) 610-6200

NPI assigned

Mar 17, 2020

Last updated

Mar 17, 2020By the provider in NPPES

Organization subpart

Yes

Parent organization

MODERN DENTAL, LLCAs reported in NPPES

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

Authorized official

Name

Tyler M Blackenburg, DMD

Title

Periodontist

Phone

(954) 736-7924

Specialties & licenses 2

Addresses

Locations

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

{
    "created_epoch": "1584403200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584403200000",
    "number": "1437785847",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14575 TAMIAMI TRL STE A",
            "city": "NORTH PORT",
            "state": "FL",
            "postal_code": "342872743",
            "telephone_number": "941-888-2362"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "706 SW PINE ISLAND RD",
            "address_2": "SUITE 103",
            "city": "CAPE CORAL",
            "state": "FL",
            "postal_code": "33991",
            "telephone_number": "941-610-6200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN DENTAL CAPE CORAL PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MODERN DENTAL, LLC",
        "enumeration_date": "2020-03-17",
        "last_updated": "2020-03-17",
        "certification_date": "2020-03-17",
        "status": "A",
        "authorized_official_last_name": "BLACKENBURG",
        "authorized_official_first_name": "TYLER",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PERIODONTIST",
        "authorized_official_telephone_number": "954-736-7924",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2020; 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.