Provider Demographics
NPI:1568735785
Name:PURI, VIKAS
Entity Type:Individual
Prefix:
First Name:VIKAS
Middle Name:
Last Name:PURI
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 1:9423 GLENCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4150
Mailing Address - Country:US
Mailing Address - Phone:260-416-2125
Mailing Address - Fax:
Practice Address - Street 1:11150 FAIRFAX BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5066
Practice Address - Country:US
Practice Address - Phone:703-934-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-18
Last Update Date:2012-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014134411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics