Healthcare Provider Details

I. General information

NPI: 1639487481
Provider Name (Legal Business Name): ANTARA D DARU DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE STE 300
ALEXANDRIA VA
22304-1306
US

IV. Provider business mailing address

4660 KENMORE AVE STE 300
ALEXANDRIA VA
22304-1306
US

V. Phone/Fax

Practice location:
  • Phone: 703-823-2422
  • Fax:
Mailing address:
  • Phone: 703-823-2422
  • Fax: 703-823-2489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401412906
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: