MEDICARE: PARAG MODI DMD, INC

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
1	1223G0001X	General Practice Dentistry	30.022930	NY

General Provider Information

NPI Number	:	1902041650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARAG MODI DMD, INC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:	315-454-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1922 W MAIN ST
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-1017
Country	:	US
Telephone Number	:	937-332-8900
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PARAG MODI
Credential	:	DDS
Telephone Number	:	937-332-8900

Provider Enumeration Date	:	12/10/2008
Last Update Date	:	12/10/2008

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