Provider Demographics
NPI:1891274759
Name:MODARRES DENTAL GROUP
Entity Type:Organization
Organization Name:MODARRES DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODARRES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:443-928-9697
Mailing Address - Street 1:7000 BRAEBURN PL
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-4908
Mailing Address - Country:US
Mailing Address - Phone:443-928-9697
Mailing Address - Fax:
Practice Address - Street 1:10132 BALTIMORE NATIONAL PIKE STE C
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3607
Practice Address - Country:US
Practice Address - Phone:410-465-3224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty