Provider Demographics
NPI:1134329030
Name:TEJAS MODI DDS INC
Entity Type:Organization
Organization Name:TEJAS MODI DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEJAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-657-1203
Mailing Address - Street 1:75 W. NUEVO RD, SUITE A & B
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-0801
Mailing Address - Country:US
Mailing Address - Phone:951-657-1203
Mailing Address - Fax:
Practice Address - Street 1:75 W NUEVO RD STE A&B
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571
Practice Address - Country:US
Practice Address - Phone:951-657-1203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD50823122300000X
CAD36129122300000X
CAD43182122300000X
CAD54136122300000X
CAD 471311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty