Healthcare Provider Details

I. General information

NPI: 1902731086
Provider Name (Legal Business Name): JINKLE PRIVESH MODI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 TAYLOR AVE STE 1
MOUNT PLEASANT WI
53405-4642
US

IV. Provider business mailing address

113 CAMBRIAN CT
ROSELLE IL
60172-4775
US

V. Phone/Fax

Practice location:
  • Phone: 262-379-8761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6002193-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: