Provider Demographics
NPI:1346623147
Name:MODUGNO, JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:MODUGNO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2614
Mailing Address - Country:US
Mailing Address - Phone:330-471-5950
Mailing Address - Fax:
Practice Address - Street 1:1320 MERCY DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2614
Practice Address - Country:US
Practice Address - Phone:330-471-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-024466122300000X
OHRES.3620122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist