Provider Demographics
NPI:1073744777
Name:MODI, NISHIT R
Entity Type:Individual
Prefix:
First Name:NISHIT
Middle Name:R
Last Name:MODI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 QUEEN ST
Mailing Address - Street 2:#3
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1547
Mailing Address - Country:US
Mailing Address - Phone:860-863-5831
Mailing Address - Fax:
Practice Address - Street 1:685 QUEEN ST
Practice Address - Street 2:#3
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1547
Practice Address - Country:US
Practice Address - Phone:860-863-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0105811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice