Individual
DR. IAN E MODESTOW
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
190 NONOTUCK ST, SUITE 103, FLORENCE, MA 01062-1911
(413) 586-5887
(413) 586-5978
Mailing address
190 NONOTUCK ST, SUITE 103, FLORENCE, MA 01062-1911
(413) 586-5887
(413) 586-5978
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
20017
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20017
MA DENTAL LICENSE
MA
01
—
X11346
BLUE CROSS BLUE SHIELD MA
MA
Enumeration date
01/23/2006
Last updated
07/08/2007
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