Provider Demographics
NPI:1053749119
Name:KALOMBO, LOUIS BWANA (DDS)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:BWANA
Last Name:KALOMBO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5473 ANNE LY LANE
Mailing Address - Street 2:ALEXANDRIA
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310
Mailing Address - Country:US
Mailing Address - Phone:703-282-8347
Mailing Address - Fax:
Practice Address - Street 1:5473 ANNE LY LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-1878
Practice Address - Country:US
Practice Address - Phone:703-282-8347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1001312122300000X
VA0401414224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist