Provider Demographics
NPI:1093145559
Name:MISTRY, MONIL (DMD)
Entity Type:Individual
Prefix:
First Name:MONIL
Middle Name:
Last Name:MISTRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 BUTLER RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:GLYDON
Mailing Address - State:MD
Mailing Address - Zip Code:21071
Mailing Address - Country:US
Mailing Address - Phone:410-833-6200
Mailing Address - Fax:
Practice Address - Street 1:4821 BUTLER RD STE 2B
Practice Address - Street 2:
Practice Address - City:GLYDON
Practice Address - State:MD
Practice Address - Zip Code:21071-2107
Practice Address - Country:US
Practice Address - Phone:410-833-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist