Provider Demographics
NPI:1720134091
Name:LUIS, MODESTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MODESTO
Middle Name:
Last Name:LUIS
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 1:5238 LOS CABALLEROS WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:323-249-7565
Practice Address - Street 1:4444 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6304
Practice Address - Country:US
Practice Address - Phone:323-564-2444
Practice Address - Fax:323-249-7565
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA364011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD36401Medicaid