Provider Demographics
NPI:1932538253
Name:MODERN ORTHODONTICS
Entity Type:Organization
Organization Name:MODERN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOLAY
Authorized Official - Middle Name:DIMITROV
Authorized Official - Last Name:MOLLOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:703-436-0006
Mailing Address - Street 1:10298 BRISTOW CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2200
Mailing Address - Country:US
Mailing Address - Phone:703-436-0006
Mailing Address - Fax:
Practice Address - Street 1:10298 BRISTOW CENTER DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2200
Practice Address - Country:US
Practice Address - Phone:703-436-0006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014135311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty