MEDICARE: DR. SURYA PRAKASH DHAKAR DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401410078	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14534	OTHER	VA	DORAL DENTAL
2	817248	OTHER	VA	UNITED CONCORDIA

General Provider Information

NPI Number	:	1063515617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SURYA PRAKASH DHAKAR DDS

Provider Business Mailing Address
First Line	:	4440 SPRINGFIELD RD
Second Line	:	STE 101
City	:	GUN ALLEN
State	:	VA
Zip	:	23060
Country	:	US
Telephone Number	:	804-217-9820
Fax Number	:	804-217-9822

Provider Business Practice Location Address
First Line	:	4440 SPRINGFIELD RD
Second Line	:	STE 101
City	:	GUN ALLEN
State	:	VA
Zip	:	23060
Country	:	US
Telephone Number	:	804-217-9820
Fax Number	:	804-217-9822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	07/08/2007

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