=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609499151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCE WILLIAM DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2020
-----------------------------------------------------
Last Update Date | 05/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7051 HEATHCOTE VILLAGE WAY STE 100
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-667-0516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43313 BARNSTEAD DR
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20148-6890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-667-0516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/ OWNER
-----------------------------------------------------
Name | DR. MADHUSUDHAN REDDY KASIPATHY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 848-667-0516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------