Provider Demographics
NPI:1972787380
Name:MOSTOFI, MINA T (DMD)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:T
Last Name:MOSTOFI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010078101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice