=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962189704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATASHA BHARUCHA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2023
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13350 FRANKLIN FARM RD
-----------------------------------------------------
City | HERNDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20171-4091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-641-0525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4652 HALLOWED STRM
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21042-6002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-641-0525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 04101418351
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------