Provider Demographics
NPI:1689074346
Name:MODI, NISHA (DMD)
Entity Type:Individual
Prefix:
First Name:NISHA
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 1:8628 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4201
Mailing Address - Country:US
Mailing Address - Phone:214-864-6515
Mailing Address - Fax:
Practice Address - Street 1:1001 S HIGHWAY 377
Practice Address - Street 2:107
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227
Practice Address - Country:US
Practice Address - Phone:469-346-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-01
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist