Provider Demographics
NPI:1972996114
Name:KISHORE THAMMINENI DENTAL ASSOCIATES DDS PC
Entity Type:Organization
Organization Name:KISHORE THAMMINENI DENTAL ASSOCIATES DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KISHORE BABU
Authorized Official - Middle Name:
Authorized Official - Last Name:THAMMINENI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-942-3458
Mailing Address - Street 1:1330 AMHERST ST STE B
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3000
Mailing Address - Country:US
Mailing Address - Phone:305-942-3458
Mailing Address - Fax:540-773-3284
Practice Address - Street 1:20876 ISHERWOOD TER APT 101
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7788
Practice Address - Country:US
Practice Address - Phone:305-942-3458
Practice Address - Fax:540-773-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014140791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty