Provider Demographics
NPI:1477160547
Name:MODARESI & AVIN DDS PLLC
Entity Type:Organization
Organization Name:MODARESI & AVIN DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODARESI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-334-8209
Mailing Address - Street 1:24805 PINEBROOK RD STE 112
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4127
Mailing Address - Country:US
Mailing Address - Phone:571-334-8209
Mailing Address - Fax:
Practice Address - Street 1:24805 PINEBROOK RD STE 112
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-4127
Practice Address - Country:US
Practice Address - Phone:571-334-8209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty