MEDICARE: GAINESVILLE FAMILY DENTISTRY, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401410429	VA

General Provider Information

NPI Number	:	1467617373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAINESVILLE FAMILY DENTISTRY, PLC

Provider Business Mailing Address
First Line	:	14535 JOHN MARSHALL HWY STE 101
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-4024
Country	:	US
Telephone Number	:	703-586-8784
Fax Number	:

Provider Business Practice Location Address
First Line	:	14535 JOHN MARSHALL HWY STE 101
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-4024
Country	:	US
Telephone Number	:	703-586-8784
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. RAMA GOSWAMI
Credential	:	DDS
Telephone Number	:	703-586-8784

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	07/21/2008

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