Provider Demographics
NPI:1659426369
Name:MODESTO, DANIELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIELA
Middle Name:
Last Name:MODESTO
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 1:2500 E COMMERCIAL BLVD
Mailing Address - Street 2:STE G
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4124
Mailing Address - Country:US
Mailing Address - Phone:954-990-6278
Mailing Address - Fax:954-990-6293
Practice Address - Street 1:2797 NE 207TH ST
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1471
Practice Address - Country:US
Practice Address - Phone:305-935-2797
Practice Address - Fax:305-937-4834
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17097122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist