Healthcare Provider Details

I. General information

NPI: 1851641799
Provider Name (Legal Business Name): SOUMYATA MANJUNATHA HEGGADE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 COMMERCE ST
SPRINGFIELD VA
22150-3411
US

IV. Provider business mailing address

7227 COMMERCE ST
SPRINGFIELD VA
22150-3411
US

V. Phone/Fax

Practice location:
  • Phone: 703-992-7778
  • Fax:
Mailing address:
  • Phone: 703-992-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413726
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413726
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: