Organization
DENTAL FAMILY PRACTICE
Active
Other names
Lake Ridge Dental Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MINA T MOSTOFI DMD (DENTIST)
(703) 494-9171
Entity
Organization
Contact information
Practice address
12724 DIRECTORS LOOP, LAKE RIDGE, VA 22192-2462
(703) 494-9171
(703) 490-4066
Mailing address
12724 DIRECTORS LOOP, LAKE RIDGE, VA 22192-2462
(703) 494-9171
(703) 490-4066
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
0401007810
VA
1223P0300X
Periodontics
0401008961
VA
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
0401410790
VA
Other
Enumeration date
04/04/2007
Last updated
06/23/2008
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