Provider Demographics
NPI:1316314214
Name:MODICA, TANYA ANN (DMD)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:ANN
Last Name:MODICA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 FRANKLIN AVE
Mailing Address - Street 2:SUITE #204
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5806
Mailing Address - Country:US
Mailing Address - Phone:516-742-4422
Mailing Address - Fax:
Practice Address - Street 1:520 FRANKLIN AVE
Practice Address - Street 2:SUITE #204
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5806
Practice Address - Country:US
Practice Address - Phone:516-742-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0580531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice