Provider Demographics
NPI:1609499151
Name:PRINCE WILLIAM DENTAL LLC
Entity Type:Organization
Organization Name:PRINCE WILLIAM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHUSUDHAN
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:KASIPATHY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:848-667-0516
Mailing Address - Street 1:43313 BARNSTEAD DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6890
Mailing Address - Country:US
Mailing Address - Phone:848-667-0516
Mailing Address - Fax:
Practice Address - Street 1:7051 HEATHCOTE VILLAGE WAY STE 100
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3197
Practice Address - Country:US
Practice Address - Phone:848-667-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316100639OtherMADHUSUDHAN KASIPATHY
VA1750583738OtherKOWSHIK VADDI