Provider Demographics
NPI:1558746974
Name:MODHA, HARESH (DDS)
Entity Type:Individual
Prefix:
First Name:HARESH
Middle Name:
Last Name:MODHA
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 1:15 COLLINS INDUSTRIAL WAY STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6029
Mailing Address - Country:US
Mailing Address - Phone:770-962-3191
Mailing Address - Fax:
Practice Address - Street 1:15 COLLINS INDUSTRIAL WAY STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6029
Practice Address - Country:US
Practice Address - Phone:770-962-3191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN213771223G0001X
GADN0151341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice