Provider Demographics
NPI:1528188471
Name:SRIRAM, KANAKA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KANAKA
Middle Name:
Last Name:SRIRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:KANAKAVALLI
Other - Middle Name:
Other - Last Name:SUBRAMANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BDS
Mailing Address - Street 1:410 MAPLE AVE W STE 2
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4224
Mailing Address - Country:US
Mailing Address - Phone:703-255-2326
Mailing Address - Fax:703-255-2325
Practice Address - Street 1:410 MAPLE AVE W STE 2
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4224
Practice Address - Country:US
Practice Address - Phone:703-255-2326
Practice Address - Fax:703-255-2325
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice