Provider Demographics
NPI:1699276279
Name:MODAK, CHARUTA (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARUTA
Middle Name:
Last Name:MODAK
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 1:3141 SONIA TRL
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3276
Mailing Address - Country:US
Mailing Address - Phone:405-208-9823
Mailing Address - Fax:
Practice Address - Street 1:4510 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1506
Practice Address - Country:US
Practice Address - Phone:410-233-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD166691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice