Healthcare Provider Details

I. General information

NPI: 1922992510
Provider Name (Legal Business Name): FANCY CHRISTINA KUMARARAJA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14346 WARWICK BLVD
NEWPORT NEWS VA
23602-3814
US

IV. Provider business mailing address

115 BEACH 62ND ST UNIT B
ARVERNE NY
11692-1884
US

V. Phone/Fax

Practice location:
  • Phone: 754-755-8771
  • Fax:
Mailing address:
  • Phone: 718-374-1224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419614
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: