Healthcare Provider Details

I. General information

NPI: 1316867500
Provider Name (Legal Business Name): POOJA VIJAY BHAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 GALLOWS RD APT 632
VIENNA VA
22180
US

IV. Provider business mailing address

2750 GALLOWS RD APT 632
VIENNA VA
22180
US

V. Phone/Fax

Practice location:
  • Phone: 703-389-1743
  • Fax:
Mailing address:
  • Phone: 703-389-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401420093
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: