Provider Demographics
NPI:1922099456
Name:MODHVADIA, VANRAJ M (DDS)
Entity Type:Individual
Prefix:
First Name:VANRAJ
Middle Name:M
Last Name:MODHVADIA
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 1:3122 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-6003
Mailing Address - Country:US
Mailing Address - Phone:901-353-2424
Mailing Address - Fax:901-353-2121
Practice Address - Street 1:3122 THOMAS ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-6003
Practice Address - Country:US
Practice Address - Phone:901-353-2424
Practice Address - Fax:901-353-2121
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist