=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023492881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HIMANSHU MEHROTRA D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2015
-----------------------------------------------------
Last Update Date | 12/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 392 GARRISONVILLE RD STE 205
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-1576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-659-6816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 392 GARRISONVILLE RD STE 205
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-1576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-736-1647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 31307
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401418371
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------