Provider Demographics
NPI:1285296814
Name:SOUTH RIDING ORAL AND IMPLANT SURGERY
Entity type:Organization
Organization Name:SOUTH RIDING ORAL AND IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:571-218-0878
Mailing Address - Street 1:9209 MAROVELLI FOREST DR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-3456
Mailing Address - Country:US
Mailing Address - Phone:571-218-0878
Mailing Address - Fax:
Practice Address - Street 1:24805 PINEBROOK RD # 318
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-4126
Practice Address - Country:US
Practice Address - Phone:571-218-0878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty