Provider Demographics
NPI:1093889008
Name:BARRY R. MAHARAJ, DDS & ANH H. PHAM, DDS, PC
Entity Type:Organization
Organization Name:BARRY R. MAHARAJ, DDS & ANH H. PHAM, DDS, PC
Other - Org Name:LANSDOWNE ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRCT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAITI
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM
Authorized Official - Phone:703-723-7858
Mailing Address - Street 1:19441 GOLF VISTA PLAZA
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-723-7858
Mailing Address - Fax:703-723-7882
Practice Address - Street 1:19441 GOLF VISTA PLAZA
Practice Address - Street 2:SUITE 130
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-723-7858
Practice Address - Fax:703-723-7882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
VA04010063041223S0112X
VA04014103051223S0112X
VA04014131711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD292375OtherMAMSI OP CHOICE ALLIANCE
VA384081OtherBCBS
VA008000531Medicaid
MD455676OtherMAMSI OP CHOICE ALLIANCE
VA008000492Medicaid
VA384338OtherBCBS