Provider Demographics
NPI:1053842245
Name:MODESTOW FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:MODESTOW FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSBERGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-586-5887
Mailing Address - Street 1:190 NONOTUCK STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1934
Mailing Address - Country:US
Mailing Address - Phone:413-586-5887
Mailing Address - Fax:
Practice Address - Street 1:190 NONOTUCK STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-1934
Practice Address - Country:US
Practice Address - Phone:413-586-5887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty