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General NPI Number Information
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NPI Number | 1730422247
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Entity Type | Organization
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Legal Business Name | DANIELA MODESTO GRAN DENTAL INC.
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Dates
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Enumeration Date | 04/03/2013
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 2500 E COMMERCIAL BLVD SUITE E
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-4124
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Country | US
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Telephone | 954-662-7447
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 PARKVIEW DR APT 720
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City | HALLANDALE BEACH
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State | FL
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Zip | 33009-2932
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Country | US
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Telephone | 954-554-3490
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Fax |
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Authorized Official
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Title or Position | DENTIST/PRESIDENT
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Name | DR. DANIELA MODESTO
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Credential | DDS
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Telephone | 954-554-3490
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN 17097
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN17097
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License Number State | FL
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