Provider Demographics
NPI:1477655322
Name:MATHURA, VIJAY
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:MATHURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 BALTIMORE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3234
Mailing Address - Country:US
Mailing Address - Phone:301-927-2500
Mailing Address - Fax:301-927-2555
Practice Address - Street 1:7305 BALTIMORE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3234
Practice Address - Country:US
Practice Address - Phone:301-927-2500
Practice Address - Fax:301-927-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist