Provider Demographics
NPI:1528632684
Name:MODLIN, SARA BETH (DDS)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:BETH
Last Name:MODLIN
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 1:589 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3231
Mailing Address - Country:US
Mailing Address - Phone:646-870-5652
Mailing Address - Fax:
Practice Address - Street 1:589 BROADWAY FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3231
Practice Address - Country:US
Practice Address - Phone:646-870-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-09-06
Deactivation Date:2021-07-08
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
NY0640191223G0001X
CT132101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice