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NPI Code Detail

MEDICARE: DR. ANDREW MODI DDS

MEDICARE: DR. ANDREW MODI DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry019024927IL

General Provider Information

NPI Number : 1538353818
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ANDREW MODI DDS
Provider Business Mailing Address
First Line : 95 W GRAND AVE
Second Line :
City : LAKE VILLA
State : IL
Zip : 60046-8641
Country : US
Telephone Number : 847-356-2336
Fax Number :
Provider Business Practice Location Address
First Line : 95 W GRAND AVE
Second Line :
City : LAKE VILLA
State : IL
Zip : 60046-8641
Country : US
Telephone Number : 847-356-2336
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2007
Last Update Date : 11/07/2007

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