Provider Demographics
NPI:1851675185
Name:MINA MODARESI DDS PC
Entity Type:Organization
Organization Name:MINA MODARESI DDS PC
Other - Org Name:REGAL DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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:703-433-1122
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty