Provider Demographics
NPI:1497886550
Name:MODY, NITIN OCHHAVLAL (DDS)
Entity Type:Individual
Prefix:
First Name:NITIN
Middle Name:OCHHAVLAL
Last Name:MODY
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 1:2701 FIRESTONE BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2778
Mailing Address - Country:US
Mailing Address - Phone:323-564-6906
Mailing Address - Fax:
Practice Address - Street 1:2701 FIRESTONE BLVD STE G
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2778
Practice Address - Country:US
Practice Address - Phone:323-564-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA359491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90929-01OtherDENTICAL