Provider Demographics
NPI:1891066486
Name:MODESTO, ARYAM (DMD)
Entity type:Individual
Prefix:DR
First Name:ARYAM
Middle Name:
Last Name:MODESTO
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 1:266 HARRISTOWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3302
Mailing Address - Country:US
Mailing Address - Phone:201-652-0400
Mailing Address - Fax:
Practice Address - Street 1:266 HARRISTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3302
Practice Address - Country:US
Practice Address - Phone:201-652-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI24929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist