Provider Demographics
NPI:1619642733
Name:KANODIA, DIVYA
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:KANODIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 15TH ST NW APT 216
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-2136
Mailing Address - Country:US
Mailing Address - Phone:617-230-2904
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 307
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2462
Practice Address - Country:US
Practice Address - Phone:703-815-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014176221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics