Provider Demographics
NPI:1538353818
Name:MODI, ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8641
Mailing Address - Country:US
Mailing Address - Phone:847-356-2336
Mailing Address - Fax:
Practice Address - Street 1:95 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8641
Practice Address - Country:US
Practice Address - Phone:847-356-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190249271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice