=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437496239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEDA MODARESI DDS, MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2013
-----------------------------------------------------
Last Update Date | 07/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13114 120TH AVE NE
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98034-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-296-7555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10829 101ST PL NE
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98033-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-394-4105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401414922
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DE60903814
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------