Healthcare Provider Details

I. General information

NPI: 1619469533
Provider Name (Legal Business Name): VIDUR JORDAN KATYAL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8314 TRAFORD LN STE A
WEST SPRINGFIELD VA
22152-1661
US

IV. Provider business mailing address

8314 TRAFORD LN STE A
WEST SPRINGFIELD VA
22152-1661
US

V. Phone/Fax

Practice location:
  • Phone: 703-451-0502
  • Fax:
Mailing address:
  • Phone: 703-451-0502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401415951
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: