Provider Demographics
NPI:1104038546
Name:KANAKA SRIRAM, D.D.S., P.C.
Entity Type:Organization
Organization Name:KANAKA SRIRAM, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KANAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-255-2326
Mailing Address - Street 1:410 MAPLE AVE W
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4240
Mailing Address - Country:US
Mailing Address - Phone:703-255-2326
Mailing Address - Fax:
Practice Address - Street 1:410 MAPLE AVE W
Practice Address - Street 2:SUITE 2
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4240
Practice Address - Country:US
Practice Address - Phone:703-255-2326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty