| NPI | 1558483305 |
|---|---|
| Other Name | LAKE RIDGE DENTAL CLINIC |
| Entity Type | Organization |
| Authorized Contact | MINA T MOSTOFI Dentist 703-494-9171 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401007810) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VA 0401008961) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401410790) | |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2008-06-23 |