=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285296814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH RIDING ORAL AND IMPLANT SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2019
-----------------------------------------------------
Last Update Date | 07/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24805 PINEBROOK RD # 318
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20152-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-218-0878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9209 MAROVELLI FOREST DR
-----------------------------------------------------
City | LORTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22079-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-218-0878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KAMRAN RAJA
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 571-218-0878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------