Healthcare Provider Details

I. General information

NPI: 1346620242
Provider Name (Legal Business Name): JEENA ELIZABETH DEVASIA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 OLD DOMINION DR SUITE 240
MC LEAN VA
22101-4504
US

IV. Provider business mailing address

6455 OLD CHESTERBROOK RD
MC LEAN VA
22101-4741
US

V. Phone/Fax

Practice location:
  • Phone: 703-734-2750
  • Fax:
Mailing address:
  • Phone: 703-356-9264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414849
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: