Healthcare Provider Details

I. General information

NPI: 1023786969
Provider Name (Legal Business Name): SHERRY L BASHAM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 09/04/2021
Certification Date: 09/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3166 GOLANSKY BLVD
WOODBRIDGE VA
22192-4263
US

IV. Provider business mailing address

15619 RHAME DR
DUMFRIES VA
22025-1107
US

V. Phone/Fax

Practice location:
  • Phone: 703-730-2931
  • Fax:
Mailing address:
  • Phone: 703-878-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402203521
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: