Provider Demographics
NPI:1447687009
Name:MODI, PRIMESH
Entity type:Individual
Prefix:
First Name:PRIMESH
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 HIGHWAY 153 STE 100
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4991
Mailing Address - Country:US
Mailing Address - Phone:423-822-8409
Mailing Address - Fax:
Practice Address - Street 1:5550 HIGHWAY 153 STE 100
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4991
Practice Address - Country:US
Practice Address - Phone:423-822-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000093151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice