=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942826524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRA DENTAL AT TYSONS CORNER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2020
-----------------------------------------------------
Last Update Date | 06/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8201 GREENSBORO DR STE 710
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-633-9455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8201 GREENSBORO DR STE 710
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL CLAIM SPECIALIST
-----------------------------------------------------
Name | DR. NIKHIL SAHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-533-4386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------