Provider Demographics
NPI:1295598985
Name:RIDGETOP DENTAL OF RESTON, PLLC
Entity type:Organization
Organization Name:RIDGETOP DENTAL OF RESTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DATTATHRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALYAVANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-313-0607
Mailing Address - Street 1:1939 ROLAND CLARKE PL STE 120
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1445
Mailing Address - Country:US
Mailing Address - Phone:571-313-0607
Mailing Address - Fax:
Practice Address - Street 1:1939 ROLAND CLARKE PL STE 120
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1445
Practice Address - Country:US
Practice Address - Phone:571-313-0607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental