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General NPI Number Information
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NPI Number | 1619642733
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Entity Type | Individual
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Provider Name | DIVYA KANODIA
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Gender | Female
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Dates
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Enumeration Date | 08/11/2021
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Last Update Date | 08/11/2021
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Provider Practice Location Address
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Address Line | 13880 BRADDOCK RD STE 307
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City | CENTREVILLE
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State | VA
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Zip | 20121-2462
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Country | US
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Telephone | 703-815-3636
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Fax |
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Provider Business Mailing Address
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Address Line | 733 15TH ST NW APT 216
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City | WASHINGTON
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State | DC
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Zip | 20005-2136
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Country | US
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Telephone | 617-230-2904
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 0401417622
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License Number State | VA
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