Healthcare Provider Details

I. General information

NPI: 1902479025
Provider Name (Legal Business Name): MODERN ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
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 Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. CYRUS F MISTRY
Title or Position: OWNER
Credential: DDS, MD
Phone: 301-610-3918