Healthcare Provider Details

I. General information

NPI: 1669827671
Provider Name (Legal Business Name): PAVANI GEDELA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46400 BENEDICT DR STE 109
STERLING VA
20164-6605
US

IV. Provider business mailing address

46400 BENEDICT DR STE 109
STERLING VA
20164-6605
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-3412
  • Fax: 703-444-3409
Mailing address:
  • Phone: 703-444-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401415868
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401415868
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: