Provider Demographics
NPI:1407183478
Name:BOGOLLAGAMA, NIRMAL CUDA (DDS)
Entity Type:Individual
Prefix:MR
First Name:NIRMAL
Middle Name:CUDA
Last Name:BOGOLLAGAMA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10751 AMBASSADOR DR # 101
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2627
Mailing Address - Country:US
Mailing Address - Phone:703-369-6969
Mailing Address - Fax:
Practice Address - Street 1:10751 AMBASSADOR DR # 101
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2627
Practice Address - Country:US
Practice Address - Phone:703-369-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410789122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice