MEDICARE: MERIL SURENDRA MODI D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1295025930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERIL SURENDRA MODI D.D.S.

Provider Business Mailing Address
First Line	:	1112 N 3RD ST
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-4301
Country	:	US
Telephone Number	:	818-497-7836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 N 3RD ST
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91504-4301
Country	:	US
Telephone Number	:	818-497-7836
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/14/2011

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