=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952651473
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PADMALATHA NAVUBOTHU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2012
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3824 MECHANICSVILLE TPKE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23223-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-767-8747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5393 KIMBERMERE CT
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23060-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-600-7688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401413762
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------