Provider Demographics
NPI:1558483305
Name:DENTAL FAMILY PRACTICE
Entity Type:Organization
Organization Name:DENTAL FAMILY PRACTICE
Other - Org Name:LAKE RIDGE DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MINA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MOSTOFI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-494-9171
Mailing Address - Street 1:12724 DIRECTORS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2462
Mailing Address - Country:US
Mailing Address - Phone:703-494-9171
Mailing Address - Fax:703-490-4066
Practice Address - Street 1:12724 DIRECTORS LOOP
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2462
Practice Address - Country:US
Practice Address - Phone:703-494-9171
Practice Address - Fax:703-490-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010078101223G0001X
VA04010089611223P0300X
VA04014107901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty