Healthcare Provider Details

I. General information

NPI: 1558483305
Provider Name (Legal Business Name): DENTAL FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12724 DIRECTORS LOOP
LAKE RIDGE VA
22192-2462
US

IV. Provider business mailing address

12724 DIRECTORS LOOP
LAKE RIDGE VA
22192-2462
US

V. Phone/Fax

Practice location:
  • Phone: 703-494-9171
  • Fax: 703-490-4066
Mailing address:
  • Phone: 703-494-9171
  • Fax: 703-490-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401007810
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401008961
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401410790
License Number StateVA

VIII. Authorized Official

Name: DR. MINA T MOSTOFI
Title or Position: DENTIST
Credential: DMD
Phone: 703-494-9171