Provider Demographics
NPI:1346623147
Name:MODUGNO, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:MODUGNO
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4820
Mailing Address - Country:US
Mailing Address - Phone:330-494-6305
Mailing Address - Fax:
Practice Address - Street 1:8340 CLEVELAND AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4820
Practice Address - Country:US
Practice Address - Phone:330-494-6305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.3620122300000X
OH30-024466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist