Provider Demographics
NPI:1629238571
Name:MONDAWMIN MALL DENTAL LLP
Entity Type:Organization
Organization Name:MONDAWMIN MALL DENTAL LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAZNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-475-7600
Mailing Address - Street 1:2401 LIBERTY HEIGHTS AVE
Mailing Address - Street 2:STE 3725
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-8019
Mailing Address - Country:US
Mailing Address - Phone:410-225-0014
Mailing Address - Fax:
Practice Address - Street 1:2401 LIBERTY HEIGHTS AVE
Practice Address - Street 2:STE 3725
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8019
Practice Address - Country:US
Practice Address - Phone:410-225-0014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty