MEDICARE: DR. ARCHANA SRINIVASAN 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	1223G0001X	General Practice Dentistry	0401412680	VA
2	122300000X	Dentist	0401412680	VA

General Provider Information

NPI Number	:	1366771792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ARCHANA SRINIVASAN DDS

Provider Business Mailing Address
First Line	:	1927 UPPER LAKE DR
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-3619
Country	:	US
Telephone Number	:	716-507-2347
Fax Number	:

Provider Business Practice Location Address
First Line	:	4319 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2401
Country	:	US
Telephone Number	:	703-897-8554
Fax Number	:

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

Provider Enumeration Date	:	12/14/2009
Last Update Date	:	06/10/2024

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