Provider Demographics
NPI:1073626818
Name:MODARESI, MINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:MODARESI
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 1:45985 REGAL PLZ
Mailing Address - Street 2:SUITE 160
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6144
Mailing Address - Country:US
Mailing Address - Phone:703-433-1122
Mailing Address - Fax:703-433-0907
Practice Address - Street 1:45985 REGAL PLZ
Practice Address - Street 2:SUITE 160
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6144
Practice Address - Country:US
Practice Address - Phone:703-433-1122
Practice Address - Fax:703-433-0907
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014100661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice