Healthcare Provider Details

I. General information

NPI: 1275621641
Provider Name (Legal Business Name): VIRINDER MODGIL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 MAIN ST POB 436
CAMDEN NY
13316-1338
US

IV. Provider business mailing address

337 N PETERBORO ST
CANASTOTA NY
13032-1154
US

V. Phone/Fax

Practice location:
  • Phone: 315-245-1445
  • Fax: 315-362-9026
Mailing address:
  • Phone: 315-697-3535
  • Fax: 315-362-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0523541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: