Provider Demographics
NPI:1083902266
Name:IAN E MODESTOW, DMD
Entity Type:Organization
Organization Name:IAN E MODESTOW, DMD
Other - Org Name:MODESTOW FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
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 ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1962
Mailing Address - Country:US
Mailing Address - Phone:413-586-5887
Mailing Address - Fax:413-584-9478
Practice Address - Street 1:190 NONOTUCK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-1962
Practice Address - Country:US
Practice Address - Phone:413-586-5887
Practice Address - Fax:413-584-9478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN200171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN20017OtherBOARD OF REGISTRATION
MADN13648OtherBOARD OF REGISTRATION