Healthcare Provider Details

I. General information

NPI: 1205006509
Provider Name (Legal Business Name): NEIL AGNIHOTRI DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 10/10/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TOWNE CENTER WEST BOULEVARD
HENRICO VA
23233-7100
US

IV. Provider business mailing address

11545A NUCKOLS ROAD
GLEN ALLEN VA
23059-5666
US

V. Phone/Fax

Practice location:
  • Phone: 804-270-5028
  • Fax: 804-747-3599
Mailing address:
  • Phone: 804-673-8061
  • Fax: 804-673-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0101247300
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401412743
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02234700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: