Provider Demographics
NPI:1548678204
Name:MODY, KHUSHBU
Entity type:Individual
Prefix:
First Name:KHUSHBU
Middle Name:
Last Name:MODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 S MICHIGAN AVE APT 1802
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2864
Mailing Address - Country:US
Mailing Address - Phone:832-622-6290
Mailing Address - Fax:
Practice Address - Street 1:3885 MUNDY MILL RD STE 116
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-3432
Practice Address - Country:US
Practice Address - Phone:832-622-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30059122300000X
GADN015958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist