Healthcare Provider Details

I. General information

NPI: 1275806226
Provider Name (Legal Business Name): SBK DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 BEAUREGARD ST SUITE 300
ALEXANDRIA VA
22312-1709
US

IV. Provider business mailing address

4810 BEAUREGARD ST SUITE 300
ALEXANDRIA VA
22312-1709
US

V. Phone/Fax

Practice location:
  • Phone: 703-750-1099
  • Fax:
Mailing address:
  • Phone: 703-750-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411429
License Number StateVA

VIII. Authorized Official

Name: DR. SHAWN S KUMRA
Title or Position: OWNER
Credential: D.D.S
Phone: 703-750-1099