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General NPI Number Information
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NPI Number | 1548678204
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Entity Type | Individual
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Provider Name | KHUSHBU MODY
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Gender | Female
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Dates
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Enumeration Date | 07/25/2014
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Last Update Date | 09/24/2019
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Provider Practice Location Address
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Address Line | 3885 MUNDY MILL RD STE 116
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City | OAKWOOD
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State | GA
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Zip | 30566-3432
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Country | US
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Telephone | 832-622-6290
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Fax |
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Provider Business Mailing Address
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Address Line | 1160 S MICHIGAN AVE APT 1802
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City | CHICAGO
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State | IL
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Zip | 60605-2864
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Country | US
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Telephone | 832-622-6290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30059
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN015958
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License Number State | GA
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