Healthcare Provider Details

I. General information

NPI: 1134486491
Provider Name (Legal Business Name): CYRUS FAROOKH MISTRY M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6191 EXECUTIVE BLVD
ROCKVILLE MD
20852-3901
US

IV. Provider business mailing address

6191 EXECUTIVE BLVD
ROCKVILLE MD
20852-3901
US

V. Phone/Fax

Practice location:
  • Phone: 301-610-3918
  • Fax: 301-610-3781
Mailing address:
  • Phone: 301-610-3918
  • Fax: 301-610-3781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16286
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: