Provider Demographics
NPI:1568524528
Name:MODESTO-GARRIDO, MAYRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:
Last Name:MODESTO-GARRIDO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 HARRISTOWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3302
Mailing Address - Country:US
Mailing Address - Phone:201-652-0400
Mailing Address - Fax:201-447-5762
Practice Address - Street 1:266 HARRISTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3302
Practice Address - Country:US
Practice Address - Phone:201-652-0400
Practice Address - Fax:201-447-5762
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI018255011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0066028Medicaid
NJ6037704Medicaid
NJ898217OtherUNITED CONCORDIA
NJ898217OtherUNITED CONCORDIA