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General NPI Number Information
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NPI Number | 1104038546
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Entity Type | Organization
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Legal Business Name | KANAKA SRIRAM, D.D.S., P.C.
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Dates
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Enumeration Date | 05/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 410 MAPLE AVE W SUITE 2
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City | VIENNA
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State | VA
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Zip | 22180-4240
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Country | US
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Telephone | 703-255-2326
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Fax |
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Provider Business Mailing Address
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Address Line | 410 MAPLE AVE W SUITE 2
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City | VIENNA
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State | VA
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Zip | 22180-4240
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Country | US
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Telephone | 703-255-2326
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KANAKA SRIRAM
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Credential | D.D.S.
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Telephone | 703-255-2326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401007621
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License Number State | VA
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