Healthcare Provider Details

I. General information

NPI: 1730814385
Provider Name (Legal Business Name): DUSHYANTHAN NITHIYANANTHASOTHY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NORTHRIDGE LN
LEXINGTON VA
24450-3399
US

IV. Provider business mailing address

95 WILLOW SPRINGS RD APT A21
LEXINGTON VA
24450-2902
US

V. Phone/Fax

Practice location:
  • Phone: 540-464-8700
  • Fax:
Mailing address:
  • Phone: 347-493-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418045
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: