Provider Demographics
NPI:1497149132
Name:RAJA, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:RAJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:MEHBOOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6954 JEREMIAH CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-4392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6954 JEREMIAH CT
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20111-4392
Practice Address - Country:US
Practice Address - Phone:571-594-1631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0588401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program