Provider Demographics
NPI:1962986422
Name:MODI, KORAL A (DMD)
Entity type:Individual
Prefix:
First Name:KORAL
Middle Name:A
Last Name:MODI
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 1:441 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-1513
Mailing Address - Country:US
Mailing Address - Phone:732-727-0474
Mailing Address - Fax:
Practice Address - Street 1:441 GORDON ST
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-1513
Practice Address - Country:US
Practice Address - Phone:732-727-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102731800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist