MEDICARE: MICHELLE EMILY MODAD

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	1223D0004X	Dental Anesthesiology	DE61149859	WA

General Provider Information

NPI Number	:	1982100475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE EMILY MODAD

Provider Business Mailing Address
First Line	:	2519 13TH AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-5008
Country	:	US
Telephone Number	:	573-308-0333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3023 80TH AVE SE STE 200
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-6014
Country	:	US
Telephone Number	:	206-690-5417
Fax Number	:

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

Provider Enumeration Date	:	04/03/2018
Last Update Date	:	07/15/2024

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Directions to “ MICHELLE EMILY MODAD ” Practice Location

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