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General NPI Number Information
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NPI Number | 1174203871
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Entity Type | Organization
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Legal Business Name | ROOT MODERN DENTISTRY
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | 250 N WASHINGTON HWY STE A
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City | ASHLAND
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State | VA
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Zip | 23005-1624
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Country | US
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Telephone | 804-406-4404
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Fax |
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Provider Business Mailing Address
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Address Line | 122 LAURADELL RD
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City | ASHLAND
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State | VA
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Zip | 23005-8228
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Country | US
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Telephone | 202-489-5972
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. CHRISKA MUSTAFA
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Credential | DDS
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Telephone | 202-489-5972
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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