Provider Demographics
NPI:1992867840
Name:OSAMA S MODJODIDI DMD
Entity Type:Organization
Organization Name:OSAMA S MODJODIDI DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MODJODIDI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-497-8611
Mailing Address - Street 1:5101 PRINCESS ANNE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-497-8611
Mailing Address - Fax:757-499-7730
Practice Address - Street 1:5101 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-497-8611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107831223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty