Provider Demographics
NPI:1396363156
Name:MODI, RIMA (DMD)
Entity Type:Individual
Prefix:DR
First Name:RIMA
Middle Name:
Last Name:MODI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N WEBER RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-1508
Mailing Address - Country:US
Mailing Address - Phone:331-757-4181
Mailing Address - Fax:
Practice Address - Street 1:702 S WEBER RD UNIT 1509
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-3058
Practice Address - Country:US
Practice Address - Phone:512-514-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist