Provider Demographics
NPI:1538471131
Name:MAHAJAN, SUSHANT (DMD, MS)
Entity Type:Individual
Prefix:
First Name:SUSHANT
Middle Name:
Last Name:MAHAJAN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 LAUREL ST
Mailing Address - Street 2:#200
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-3930
Mailing Address - Country:US
Mailing Address - Phone:678-910-0823
Mailing Address - Fax:
Practice Address - Street 1:691 LAUREL ST
Practice Address - Street 2:#200
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3930
Practice Address - Country:US
Practice Address - Phone:678-910-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014135801223E0200X
DCDEN10011271223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodontics