Provider Demographics
NPI:1700868973
Name:MODIRI, ALI (DDS)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MODIRI
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 1:44 STRAWBERRY HILL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2632
Mailing Address - Country:US
Mailing Address - Phone:917-658-5863
Mailing Address - Fax:
Practice Address - Street 1:44 STRAWBERRY HILL AVE STE 1
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2632
Practice Address - Country:US
Practice Address - Phone:917-658-5863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0093631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1700868973Medicaid
CT002093631Medicaid