Provider Demographics
NPI:1851902696
Name:BUDDHA, VIVEK
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:
Last Name:BUDDHA
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 1:2917 LAUREL WOODS LN
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1622
Mailing Address - Country:US
Mailing Address - Phone:707-205-6927
Mailing Address - Fax:
Practice Address - Street 1:2040 COLISEUM DR # A27
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3200
Practice Address - Country:US
Practice Address - Phone:757-262-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014171221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty