=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801948922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER NORBERT MODJESKI DDS, CAGS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 01/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 SAN JOSE ST # 3
-----------------------------------------------------
City | SALINAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93901-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-758-1672
-----------------------------------------------------
Fax | 831-758-1137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 SAN JOSE ST # 3
-----------------------------------------------------
City | SALINAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93901-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-758-1672
-----------------------------------------------------
Fax | 831-758-1137
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 53685
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------