Provider Demographics
NPI:1902479025
Name:MODERN ORAL & FACIAL SURGERY
Entity Type:Organization
Organization Name:MODERN ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRUS
Authorized Official - Middle Name:F
Authorized Official - Last Name:MISTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:301-610-3918
Mailing Address - Street 1:6191 EXECUTIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3901
Mailing Address - Country:US
Mailing Address - Phone:301-610-3918
Mailing Address - Fax:301-610-3781
Practice Address - Street 1:6191 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3901
Practice Address - Country:US
Practice Address - Phone:301-610-3918
Practice Address - Fax:301-610-3781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty