Healthcare Provider Details

I. General information

NPI: 1023139466
Provider Name (Legal Business Name): SAMEER KWATRA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 PRINCE WILLIAM PKWY
WOODBRIDGE VA
22192-4145
US

IV. Provider business mailing address

7921 N PARK ST
DUNN LORING VA
22027-1221
US

V. Phone/Fax

Practice location:
  • Phone: 703-583-7720
  • Fax:
Mailing address:
  • Phone: 703-992-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401410643
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: