Provider Demographics
NPI:1508989799
Name:BALAKRISHNAN, RAJESH (DDS)
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:BALAKRISHNAN
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 1:19415 DEERFIELD AVE
Mailing Address - Street 2:BLDG 1 SUITE 207
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8452
Mailing Address - Country:US
Mailing Address - Phone:571-223-2434
Mailing Address - Fax:571-223-2919
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:BLDG 1 SUITE 207
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8452
Practice Address - Country:US
Practice Address - Phone:571-223-2434
Practice Address - Fax:571-223-2919
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice