Provider Demographics
NPI:1336200591
Name:OSORIO-MODRELL, AMINDA (DDS)
Entity type:Individual
Prefix:
First Name:AMINDA
Middle Name:
Last Name:OSORIO-MODRELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 DANVILLE BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507
Mailing Address - Country:US
Mailing Address - Phone:925-837-6052
Mailing Address - Fax:925-837-3768
Practice Address - Street 1:3176 DANVILLE BLVD
Practice Address - Street 2:STE 2
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507
Practice Address - Country:US
Practice Address - Phone:925-837-6052
Practice Address - Fax:925-837-3768
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA2348675122300000X
CA54022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist