Provider Demographics
NPI:1174203871
Name:ROOT MODERN DENTISTRY
Entity type:Organization
Organization Name:ROOT MODERN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-489-5972
Mailing Address - Street 1:122 LAURADELL RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-8228
Mailing Address - Country:US
Mailing Address - Phone:202-489-5972
Mailing Address - Fax:
Practice Address - Street 1:250 N WASHINGTON HWY STE A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1624
Practice Address - Country:US
Practice Address - Phone:804-406-4404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental