Provider Demographics
NPI:1366771792
Name:SRINIVASAN, ARCHANA (DDS)
Entity type:Individual
Prefix:DR
First Name:ARCHANA
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 UPPER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3619
Mailing Address - Country:US
Mailing Address - Phone:716-507-2347
Mailing Address - Fax:
Practice Address - Street 1:4319 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2401
Practice Address - Country:US
Practice Address - Phone:703-897-8554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014126801223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice