Provider Demographics
NPI:1902026560
Name:COLOSPATE, VIDYA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIDYA
Middle Name:R
Last Name:COLOSPATE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6845 ELM ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-6007
Mailing Address - Country:US
Mailing Address - Phone:703-356-5330
Mailing Address - Fax:703-356-7239
Practice Address - Street 1:6845 ELM ST
Practice Address - Street 2:SUITE 500
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-6007
Practice Address - Country:US
Practice Address - Phone:703-356-5330
Practice Address - Fax:703-356-7239
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014115461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice