Healthcare Provider Details

I. General information

NPI: 1467379230
Provider Name (Legal Business Name): ILLUMINATE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 K ST NW STE 820
WASHINGTON DC
20006-1003
US

IV. Provider business mailing address

9359 BRAYMORE CIR
FAIRFAX STATION VA
22039-3129
US

V. Phone/Fax

Practice location:
  • Phone: 202-545-7774
  • Fax:
Mailing address:
  • Phone: 201-736-1647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HIMANSHU MEHROTRA
Title or Position: OWNER
Credential: DDS
Phone: 201-736-1647